CALIFORNIA STATE UNIVERSITY, FULLERTON Sponsored Project Internal Routing Form Instruction Sheet

1. Investigator Information: Enter the last name and first name, department and phone number or email address, whichever you prefer to be contacted by, of the lead investigator and all other investigators involved in the project. If there is more than one Co-Investigator please use the Continuation Page 4 of 4 that is provided. 2. Sponsor Name: Enter the name of the source of the grant or contract funds (i.e. National Institutes of Health), Division Name (i.e. National Cancer Institute) update to reflect the headings. 3. Project Title: Enter the title of the proposed project. 4. Sponsor Type: Check the box that best categorizes the type of organization from which the funds originate. 5. Project Type: Check the appropriate box to indicate whether the project will be a grant, contract or a subcontract. If contract or subcontract, also specify whether the subcontract will be a fixed price subcontract (sponsor may not require a detailed budget) or cost reimbursement subcontract (sponsor requires a detailed budget and will reimburse in increments). 6. Proposal Type: Indicate the type of proposal or contract that is being submitted for review. 7. Project Class: Check the box that best describes the nature of your project. 8. Sponsor Deadline: Check the box that appropriately describes the type of deadline and enter the deadline date for the submission of the grant proposal or contract. 9. Proposed Project Period: Enter the proposed project period for the entire length of the project (Note: for multiyear projects please enter the start date for first year and end date for the last year of the project). 10. Project Location: Indicate whether the CSUF portion of the project will take place primarily on the CSUF campus or off campus. If off campus, specify the off campus location(s). 11. Brief Description of Project: Enter a brief abstract of the proposed project (limit of 700 characters). 12. Funds Requested: Enter the proposed budget amounts in the appropriate spaces. Additionally, indicate whether the project will apply for an indirect cost waiver. If “Yes,” the Facilities and Administrative Cost Deviation Justification/Waiver must be completed and submitted to the appropriate office for authorization. Upon approval, return the form to the OGC for filing. 13. Cost Sharing: Enter the proposed cost sharing/matching amount in the appropriate space(s) and the source(s) of the funds. Also indicate whether the funds proposed are in-kind (non-monetary) or cash. (Note: The OGC recommends that only the minimum amount of cost sharing required by the sponsor be reflected in the proposal budget.) 14. Additional Budget Information & Resources: Check the appropriate box if the proposed project involves any of the listed items. For boxes marked “Equipment Purchases”, “Additional or Renovated Space”, “Special Facilities”, and “Other”, enter the associated estimated costs and the source of those funds in the spaces provided. For those boxes marked “Release/Reassigned Time” and “Overload Time”, provide the name of the faculty requesting the time, the semester or semesters in which the time 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. 15. Intellectual Property: If applicable, indicate whether the proposed project may involve a copyright, patent, trademark, or other form of intellectual property. 16. Verification of Compliance: Check the appropriate box for each item of compliance. If approval has been received enter the date of approval and the protocol number in the space provided. 17. Conflict of Interest: Provide an answer in the appropriate checkbox. If “YES,” a formal disclosure form must be completed. “Financial Interest” in the sponsor means 1) any investment in the sponsor in which you, your spouse, or your dependent children have a direct, indirect or beneficial interest totaling $2,000 or more; 2) a position as director, officer, partner, trustee, employee of or any other position of management with the sponsor; 3) your gross income and your community property interest in your spouse’s gross income totaling $500 or more; 4) gift income with a fair market value of $50 or more received within the last twelve months; or 5) loans received or outstanding totaling $500 or more received in the last 12 months. 18. Risk Management Review Items: 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. 19. Involvement of Students: If CSUF students will be involved in the proposed project, please respond to the items involved in this section. California State University, Fullerton Project # Sponsored Project Internal Routing Form

(Please see instruction sheet for information on completing this form) 1. Investigator Information: (list all faculty involved in project. If additional investigators are involved, please use continuation sheet) Last Name, First Name Department Phone/Email Principal Investigator: Co-Investigator #1 Key Personnel 2. Sponsor Name: Sponsor Institute/Division: Funding Opportunity Title: Funding Opportunity #: CFDA #: 3. Project Title:

4. Sponsor Type: Federal State Local/County 5a. Award Type: Grant Cooperative Agreement UC CSU Corp/Fdn Contract: Fixed Price Cost Reimbursement Business/Industry Non-Profit Subcontract (Prime ) Educational Institution Individual Charitable Award International 5b. Special Funding: ARRA Earmark 6. Proposal Type: Pre-Proposal Revision 7. Project Class: Service Fellowship Letter of Intent Supplement (select only one) Travel/Workshop Equipment New Proposal/ Continuation Basic Research Student Support Other Contract Renewal Applied Research Renovation/Construction Original Project # Training Curriculum Development/Instruction 8. Sponsor Postmark Date: Electronic Submission Date/Time: Deadline: Receipt Date: Requested PI Pick-up Date: 9. Proposed Project Start Date: 10. Project Location: On Campus Off Campus End Date: Period: If Off Campus, specify Location: 11. Brief Description of Project:

12. Funds Requested: First Year/Period Cumulative Project Period (if multi-year project) Direct Costs: $ $ F&A (Indirect) Cost Reduction/Waiver (Requested per F&A (Indirect) Costs*: $ $ sponsor guidelines or other justification) : Yes No Total Costs: $ $ If Yes, please see F&A Cost Deviation Justification Waiver * Current F&A (Facilities & On-Campus Rate: Off -Campus Rate: Other than established rates: Administration / Indirect) Cost 35.1% of Modified Total Direct Costs 14.8% of Modified Total Direct Costs % of (base) Rates: 13. Cost Sharing 1: Required per sponsor First Cumulative Project Cost Share Sources 2 (enter source guidelines? Yes No If Yes, % or $ req.: Year/Period Period (if multi-year project) of funds below) CSUF Cost Share ( in-kind / cash): $ $ CSUF: Third Party Cost Share ( in-kind / cash): $ $ Third Party: Total Cost Share: $ $ 14. Additional Budget Information & Resources: (Please indicate whether this project involves any of the following) Equipment Purchases 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: Released/Reassigned Time – “R” (provide detail below) Summer Overload Time – “O” (provide detail below) No Time Charged NOTE: Total faculty overload time for any given academic year is 25% maximum.

Principal Investigator (last name, first name) Semester(s) Time Type (R and/or O) %Time or # Units released

Co-Investigator #1 (last name, first name) Semester(s) Time Type (R and/or O) %Time or # Units released

Footnotes: 1 The OGC recommends that only the minimum amount of cost sharing sponsor required be reflected in the proposal budget 2 If CSUF source, commitment is made by authorized person signing this form. If a Third Party, a written commitment is needed prior to proposal submission

Page 1 of 4 Shares/Misc Doc/OGC Routing Form 01/29/10ms 15. Intellectual Property Potential Copyright Potential Invention Other (Check if applicable): Potentially Patentable Process or Idea Trademark 16. Verification of Compliance: Status Committee Approvals/Protocols N/A Not yet submitted Pending Approved (Enter Date and Protocol #) Animal Subjects Human Participants Health & Safety/Chem./Radiation Biohazards Controlled Substances 17. Conflict of Interest: Does the PI or does the Co-I have a financial interest3 that could affect or be affected by this project? - (If Yes, Note that a Disclosure Form must be completed and submitted to the OGC prior to proposal submission.) Response Response

Principal Investigator: Yes No Co-Investigator #1: Yes No 18. Risk Management Review Items Please check any of the following: Yes No Does the project involve the use of: Yes No Does the project require: Laboratory chemicals or other An agreement with a non-CSUF party (e.g. hazardous materials collaborators or consultants) involved in the proposed activity DHHS/FDA regulated materials International travel (specify country)

Recombinant DNA Modification of any University property or Controlled substance(s) the installation of equipment Bio-hazardous materials Operation at a medically-related clinic or Microbial agents facility Known carcinogen(s) Skin or scuba diving Compressed air or gas cylinders An inherently dangerous activity Handling of human blood, bodily fluids, Minors or other potentially infectious materials Non-University real property Radioactive Materials Lasers Production of medical waste Yes No Does the project involve: Yes No Does the project involve: Shipping equipment, chemicals, or Training foreign nationals in using equipment? biological agents to a foreign country? If yes, please specify equipment. If Yes, please specify item and country: The likelihood that the ASC/University will be a defendant in the event of a loss Collaborating with colleagues in foreign Working with a country subject to a US boycott, countries? If yes, specify country:. i.e., Balkans, Burma, Cuba, Iran, Iraq, Libya, Liberia, Sudan, Syria, Zimbabwe, and North Korea? (specify) Possible pollution exposure? Auto liability Is the RFP marked “Export Controlled”? Is the sponsor demanding pre-approval rights Possible property damage over publications? Liquor liability Pre-approval of participation of foreign national Professional liability students? Will this project require additional Subcontract(s) insurance coverage? (specify type)

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 Technical (i.e., Web development) Field Work Advising/Mentoring of Others Clerical/Administrative Research/Laboratory Work Training Internship Community Engagement Course Credit Page 2 of 4 Shares/Misc Doc/OGC Routing Form 01/29/10ms Note: If students are involved, OGC recommends that the PI contact Lea M. Jarnagin, Assistant to the VP Student Affairs to consult on how this proposal can be further strengthened. Her contact information is: Telephone: (714) 278-2957 / E-mail: [email protected] /Campus Address: LH-805

3 See instruction sheet for definition/clarification AUTHORIZING SIGNATURES AND APPROVALS Investigator(s) Certification: My signature below certifies that 1) I agree to be bound by the terms and conditions of the external grant or contract which supports this proposed activity; 2) I 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) My 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) I certify that I am am not currently debarred or suspended from receiving federal or state assistance and that I am am not delinquent in repaying debts to the federal government. I certify that I am aware of the federal regulations regarding Lobbying and Drug-Free Workplace and will comply as necessary. I have provided prior knowledge to my Chair and Dean about my intent to prepare this proposal. Each has provided prior approval of this submission. For NSF Science and Engineering Research or Education Proposals: As Principal Investigator, I 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. ______Principal Investigator (Signature Required) Date Co Investigator #1/Key Personnel (Signature Required) Date 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) Required University Approvals: I approve the attached proposal for a grant or contract and certify that the proposed project can be completed within my area of responsibility, within the space, financial, personnel resources and time limits available at this time. I have read the obligations required for the project and approve of the commitments expected of my unit. Title (signatory or designee) Signature(s) Date 1. Director, OGC 2. Executive Director, CSUF Aux. Services Corp. (ASC) For PI) 3. Department Chair(s) or Director(s)/Supervisor(s) For Co-I #1)

4. Director, Health Promotion Research Institute (as applicable) For PI) 5. Dean(s)/Division Head(s) For Co-I #1)

6. Vice President for Academic Affairs 7. Vice President for Administration 8. Chief Financial Officer Additional Approvals (as needed): Check One Department/ Unit Signature Date Not Applicable Yes University Risk Manager

Univ. Adv. (Corp./Fdn. Rel. Dir.)

Dean, Extended Education

Assoc. V.P., Academic Programs Environmental Health and Instructional Safety Director

Radiation Safety Officer

Physical Plant Director

Information Technology

Other: ______

Page 3 of 4 Shares/Misc Doc/OGC Routing Form 01/29/10ms Office of Grants & Contracts: Blossom Huynh Patton Tagle Office of University Research Initiatives & Partnerships: Kim-Han Health Promotion Research Institute University Advancement: Yu Special Notes / Comments:

Page 4 of 4 Shares/Misc Doc/OGC Routing Form 01/29/10ms Continuation Page CSUF Sponsored Project Internal Routing Form (Use only if two (2) or more Co-Investigators are involved in the project.)

ADDITIONAL INVESTIGATORS (SIGN AND DATE) Co-Investigator #2 Last Name, First Name Department Phone/Email Key Personnel Released/Reassigned Time Overload Time Semester(s) % Time/# of Units Released Conflict of Interest: Does the Co-I have a financial interest3 that could affect or be affected by this project? Yes No (if yes, please contact the OGC for further information) Investigator Signature Date

Co-Investigator #3 Last Name, First Name Department Phone/Email Key Personnel Released/Reassigned Time Overload Time Semester(s) % Time/# of Units Released Conflict of Interest: Does the Co-I have a financial interest3 that could affect or be affected by this project? Yes No (if yes, please contact the OGC for further information) Investigator Signature Date

Co-Investigator #4 Last Name, First Name Department Phone/Email Key Personnel Released/Reassigned Time Overload Time Semester(s) % Time/# of Units Released Conflict of Interest: Does the Co-I have a financial interest3 that could affect or be affected by this project? Yes No (if yes, please contact the OGC for further information) Investigator Signature Date

Co-Investigator #5 Last Name, First Name Department Phone/Email Key Personnel Released/Reassigned Time Overload Time Semester(s) % Time/# of Units Released Conflict of Interest: Does the Co-I have a financial interest3 that could affect or be affected by this project? Yes No (if yes, please contact the OGC for further information) Investigator Signature Date

Co-Investigator #6 Last Name, First Name Department Phone/Email Key Personnel Released/Reassigned Time Overload Time Semester(s) % Time/# of Units Released Conflict of Interest: Does the Co-I have a financial interest3 that could affect or be affected by this project? Yes No (if yes, please contact the OGC for further information) Investigator Signature Date

ADDITIONAL APPROVALS (SIGN AND DATE) For Department Chair or Director/Supervisor Dean/Division Head Co-I #2 For Department Chair or Director/Supervisor Dean/Division Head Co-I #3 For Department Chair or Director/Supervisor Dean/Division Head Co-I #4 For Department Chair or Director/Supervisor Dean/Division Head Co-I #5 For Department Chair or Director/Supervisor Dean/Division Head Co-I #6

3 See instruction sheet for definition/clarification

Page 5 of 4 Shares/Misc Doc/OGC Routing Form 01/29/10ms