California State University, Fullerton

California State University, Fullerton Sponsored Project Internal Routing Form

Project # check if this is an HPRI proposal

1. Investigator(s) Information (List all CSUF key personnel involved in the project & specify the semester or semesters in which the time requested will be provided (i.e. Spring 05), the type of time requested, and the percentage of time or the number of units of released/reassigned time being requested). Please complete page 4 for additional key personnel. Note to investigators/key personnel:  For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form (FCOI). For proposals to non-profits & other non-exempt entities  Total faculty overload time for any given academic year is 25% maximum.  Certification: Each Faculty/Staff member certifies that 1) They agree to be bound by the terms and conditions of the external grant or contract which supports this proposed activity; 620.000 (human participants), UPS 610.000 (conflict of interest) and UPS 100.005 (patents); 3) Their time commitments for this and other externally funded projects do not exceed 125% of my time during the academic year per CSU Policy, HR 2002-05, dated February 19, 2002; they are aware of the federal regulations regarding Lobbying and Drug-Free Workplace and will comply as necessary; 5) They have provided prior knowledge to their Chair and Dean about their intent to prepare this proposal. or suspended from receiving federal or state assistance and that you are not delinquent in repaying debts to the federal government.

Principal Investigator (last name, first name) Department College Please identify total time below, including any cost-match of effort. Released/Reassigned Time –% Non-Academic–% Overload Time –% No Salary Charge

Cost Match: Release Time % Cost Match: Non-Academic: %

For NSF Science and Engineering Research or Education Proposals: By signing off in Cayuse, you certify that in accordance with Section 7009 of the America Creating Opportunities to Meaningfully Promote Excellence in Technology, Education, and Science (COMPETES) Act (42 U.S.C. 18620-1), effective January 4, 2010, that at the time of proposal submission to NSF, I will have a plan to provide appropriate training and oversight in the responsible and ethical conduct of research to undergraduates, graduate students, and postdoctoral researchers who will be supported by NSF to conduct research. I acknowledge that while training plans are not required to be included in the submitted proposal that such plans will be subject to review upon request.

Role (last name, first name) Department College Please identify total time below, including any cost-match of effort.

Released/Reassigned Time –% Non-Academic–% Overload Time –% No Salary Charge

2. Sponsor Sponsor Institute/Division: Name: Program Name: Funding Opportunity #: CFDA# (if applicable): 3. Project Title: 4. Funding Source: 5. Type of Proposal: Federal Federal Flow-Through Grant Cooperative Agreement

State of CA CA State Flow-Through Contract: Fixed Price

Business/For Profit Non-Profit/Private Foundation ARRA Congressionally Directed Private-Individual Private-Alumni

FY2016-17 Version Jan. 2017 1 Foreign Source Local (includes other states, cities, county, community colleges & public school districts) 7. Kind of Application: Indicate the type of proposal or project that is being submitted for review. 8. Project Type: (select only ONE) Pre-Proposal Letter of Intent Basic Research Applied Research Research Development

New Proposal/New Contract Public Service Scholarships and Fellowships Original OGC Project Number: Revision Supplement Curriculum Development/Instruction Student Services

Continuation/Renewal Equipment Construction Training

Postmark Date: Receipt Date: 9. Sponsor Deadline: Electronic Submission Date/Time: Target Date:

Rate Applied: % Location of Project: ON campus OFF campus 10. IDC and Location: IDC Base: (specify MTDC, TDC, etc) Location (if off campus): 11. Brief Description of Project: (please provide a 2-3 sentence description)

12. Applicable keywords: (please select all that apply) External UC STEM Student research Collaborators Collaborators Other Title 2-year/community HSI External (e.g. Title IV) college Collaborators 13. Total Funds Requested: 14. Proposed Project Period: (mo/da/year) Direct Costs: $ Start Date: F&A (Indirect) Costs: $ End Date: Total Costs: $ 2 15. Cost Sharing : Cost Share Sources 3 Required per sponsor guidelines? Yes No If Yes, % or $ req.: (enter source of funds below) CSUF Cost Share ( in-kind / cash): CSUF:

Third Party Cost Share ( in-kind / cash): Third Party:

Total Cost Share: 16. Additional Budget Information & Resources (Please indicate whether this project involves any of the following):

Equipment Purchases (≥$5,000/system) Est. Costs (if applicable): $ Source:

Additional or Renovated Space Est. Costs (if applicable): $ Source:

Special Facilities Est. Costs (if applicable): $ Source:

Special Insurance Requirements Est. Costs (if applicable): $ Source:

Other Est. Costs (if applicable): $ Source:

Potential Copyright Potential Invention Other 17. Intellectual Property (Check if applicable): Potentially Patentable Process or Idea Trademark

18. Verification of Compliance: Committee Approvals/Protocols

FY2016-17 Version Jan. 2017 2 N/A Not yet submitted Animal Subjects

Human Participants

Health & Safety, Chemical/ Radioactive Materials, Radioisotopes Bio-hazardous Materials, pyrophoric, shock/friction sensitive chemicals 19. Involvement of Students Mark all that apply:

Does this project involve student hiring? Yes No Unpaid participation of CSUF students? Yes No

If Yes: Number of Undergraduate Students If Yes: Number of Undergraduate Students

Number of Graduate Students Number of Graduate Students

Please mark the appropriate description of student activity: (Mark all that apply)

Teaching/Tutoring Advising/Mentoring of Others Internship Technical (i.e., Web development)

Research/Laboratory Work Course Credit Field Work

Clerical/Administrative Training Community Engagement

20. Involvement of Post doc(s) Does this project involve hiring of post doc(s)? Yes No Name: % Effort: Name: % Effort: If Yes, please list the names of post doc, if Name: % Effort: available, or mark TBH (to be hired). 21. Risk Management Review Items (check any of the following):

In accordance with Executive Order 890, Administration of Grants and Contracts in Support of Sponsored Programs, please carefully review and respond to each specified item detailed in the listing of Risk Management Review Items.

Yes No Does the project require/ involve

Consultants, collaborators, partners

Subcontract(s)

Recombinant DNA

Liquor liability

Auto liability

Professional liability Handling of human blood, bodily fluids, or other potentially infectious materials Compressed air or gas cylinders

Radioisotope or lasers Modification of any University property or the installation of equipment

FY2016-17 Version Jan. 2017 3 Handling of export-controlled materials and/or information Shock/friction sensitive chemicals

Minors

Skin or scuba diving

An inherently dangerous activity

Non-University real property

Pyrophoric chemicals

Possible pollution exposure

Shipping equipment, chemicals, radioisotopes or biological agents, plants or soils to or from a foreign country. If Yes, please specify item and country:

21. Award Administration or Stewardship (For Office Use Only):

Award to be administered by the CSUF Auxiliary Services Corporation (ASC)

Award to be administered by the Cal State Fullerton Philanthropic Foundation (CSFPF)

Award to be administered by CSU Fullerton (STATE)

1 For proposals to NSF or PHS (e.g., NIH) PIs/co-PIs must complete the Financial Conflict of Interest (FCOI) Form. For more information on PHS/NSF Conflict of Interest definitions please see http://www.fullerton.edu/research/contact-us/Policies.asp. PIs requesting funding from non-profits and other non-public organizations must file a California Form 700-U form (see CA Fair Practices Commission website at http://www.fppc.ca.gov/index.php?id=500). Details of the Conflict of Interest policy at Cal State Fullerton can be found at http://www.fullerton.edu/research/ogc/forms-templates. 2 The OGC recommends that only the minimum amount of cost sharing sponsor required be reflected in the proposal budget. Voluntary, committed, cost-share is discouraged. Non-reportable university cost match should be appropriately identified as “internal cost-share only.” 3 If the source of cost-share is the CSUF, commitment should be made by the person authorized to approve expenditures against the CSUF account. If cost-share is from a Third Party, a written commitment from that party is needed prior to proposal submission. Additional Investigator(s) Information (List all CSUF key personnel involved in the project & specify the semester or semesters in which the time requested will be provided (i.e. Spring 05), the type of time requested, and the percentage of time or the number of units of released/reassigned time being requested). Please complete page 4 for additional key personnel. Note to investigators/key personnel:  For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form (FCOI). For proposals to non-profits & other non- exempt entities please complete the Form 700-U. Please see footnote (page 3) on Conflict of Interest1 .  Total faculty overload time for any given academic year is 25% maximum.  Certification: Each Faculty/Staff member certifies that 1) They agree to be bound by the terms and conditions of the external grant or contract which supports this proposed activity; 2) They agree to abide by the University’s research policies, including UPS 630.000 (scientific misconduct), UPS 620.000 (human participants), UPS 610.000 (conflict of interest) and UPS 100.005 (patents); 3) Their time commitments for this and other externally funded projects do not exceed 125% of my time during the academic year per CSU Policy, HR 2002-05, dated February 19, 2002; 4) They certify that they are aware of the federal regulations regarding Lobbying and Drug-Free Workplace and will comply as necessary; 5) They have provided prior knowledge to their Chair and Dean about their intent to prepare this proposal. 6) By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not delinquent in repaying debts to the federal government. Note: Total faculty overload time for any given academic year is 25% maximum. Certification: Each Faculty/Staff member certifies that 1) They agree to be bound by the terms and conditions of the external grant or contract which supports this proposed activity; 2) They agree to abide by the University’s research policies, including UPS 420.106 (scientific misconduct), UPS 420.103 (human participants), UPS 610.000 (conflict of interest) and UPS 100.005 (patents); 3) Their time commitments for this and other externally funded projects do not exceed 125% of my time during the academic year per CSU Policy, HR 2002-05, dated February 19, 2002; 4) They certify that they are aware of the federal regulations regarding Lobbying and Drug-Free Workplace and will comply as necessary; 5) They have provided prior knowledge to their Chair and Dean about their intent to prepare this proposal.

FY2016-17 Version Jan. 2017 4 Role (last name, first name) Department College Please identify total time below, including any cost-match of effort.

Certification: By signing off in Cayuse, you certify that you are not currently debarred or suspended from receiving federal or state assistance and that you are not delinquent in repaying debts to the federal government. Conflict of Interest1: For proposals to NSF & PHS (e.g., NIH), please complete a Federal Disclosure Form. For proposals to non-profits & other non-exempt entities please complete the Form 700-U. PLEASE SEE PAGE 3 OF THIS FORM.

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