Principal Investigator/Project Director Data

THE UNIVERSITY OF MEMPHIS

PROPOSAL SUMMARY FORM

PROJECT TITLE

PRINCIPAL INVESTIGATOR/PROJECT DIRECTOR DATA

Name ______/ Department/Center ______
Phone ______/ Fax ______/ E-mail ______/ Shared Credit ____ %
Co-PI/PD ______/ Shared Credit ____ % / Co-PI/PD ______/ Shared Credit ____ %
Department/Center ______/ Department/Center ______

AGENCY TRANSMITTAL DATA

Sponsor’s Name ______
ATTN: ______
Street Address ______
Bldg/Room ______
City, State ZIP ______
Sponsor’s Phone Number ______/ Requested Submission Date _______
OR
Required Deadline Date ______
Deadline Type Postmark
Receipt by Sponsor
Number of Copies ______

BUDGET DATA

Requested Start Date

Requested End Date
Requested Direct Costs
Requested Indirect Costs @______%
Total Requested Costs /

Year One

______
______
$ ______
$ ______
$ ______/ Total Period (for multi-year projects)
______
______
$ ______
$ ______
$ ______/

AWARD TERMS

Grant
Contract (Cost-reimbursable)
Contract (Fixed-fee)
Cooperative Agreement
Other ______

PROPOSAL TYPE

New
Preliminary
Renewal/Continuation *
Revision
Supplement *
Current Account Number ___ - ______/

ACTIVITY TYPE

Research
Instruction/Training
Public Service
Other /

COST-SHARING

/ YES / NO

Amount

$ ______
$ ______
$ ______
$ ______/ Source (Acct Number)
___ - ______
___ - ______
___ - ______
___ - ______

Subcontracts included?

/ YES / NO

SPECIAL REVIEWS

Human Subjects
Animal Use
Biohazards
Other (specify) /

Protocol Number

______
______
______
______/

Date Approved

______
______
______
______/

UNIVERSITY RESOURCES INVOLVED

Yes No Use/Renovation of Space Not Currently Available to Project
Yes No Use of Equipment Not Currently Available to Project
Yes No Use of Electron Microscopy Facilities
Yes No Use of Campus Telecommunication Resources
Yes No Use of Personnel Not Currently Employed by U of M

NOTES

INDIRECT COSTS: Exception to the full federal indirect cost rate is requested for
for the following reason:
State of Tennessee agency @ 15 %
Sponsor allows a maximum of ______% indirect costs as verified by:
Sponsor guidelines, page ______(or copy attached) and/or
Office of Research Support Services
Other (please specify)______
ACTIVITY LOCATION:
On-Campus
Off-Campus*
*Off-Campus Definition: For all activities performed in facilities not owned by the institution and to which rent is directly allocated to the project.

CERTIFICATIONS AND SIGNATURES

POLICIES AND PROCEDURES: By signature below, I certify that I understand that the expenditure of funds received for externally sponsored projects is subject to both sponsor guidelines and The University of Memphis Policies and Procedures. These polices and procedures are available on-line at the following web address: http://policies.memphis.edu/. Assistance in identifying applicable policies and procedures is available from Research Support Services.
CERTIFICATIONS AND ASSURANCES: By signature below, I certify that (a) I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from current transactions by a Federal department or agency; (b) I have not and will not lobby any Federal agency on behalf of this project; (c) neither
I or my immediate family currently has a business relationship with the sponsor (other than through a sponsored project administered by The University of Memphis) or other possible conflict of interest with regard to this proposal.
FINANCIAL DISCLOSURE: Complete section (below right). See University of Memphis procedure “Disclosure of Financial Interests Related to Federally Sponsored Projects” (2A:18:01A ) at http://policies.memphis.edu/2a1801a.html for complete definition of financial interests.
ALL INVESTIGATORS/PROJECT DIRECTORS MUST SIGN FINANCIAL DISCLOSURE: Do you, your spouse, or dependent children have
AND COMPLETE FINANCIAL DISCLOSURE SECTION: any financial interests related to the work to be conducted under the sponsored
project?
______
Principal Investigator/Project Director Date Yes No
______Yes No
Co-Investigator/Project Director Date
______Yes No
Co-Investigator/Project Director Date
If yes, attach the name of each entity in which you have related financial interest
and a description of financial interest for each entity.
DEPARTMENT/COLLEGE APPROVALS
The attached proposal has been reviewed and is consistent with Department and College plans and programs and requires no additional equipment, facilities, personnel time, or supporting services other than outlined in the proposal and/or indicated on this form.
FOR THE PRINCIPAL INVESTIGATOR/PROJECT DIRECTOR
______
Department Chair Date Dean Date
FOR CO-INVESTIGATORS/DIRECTORS
______
Department Chair Date Dean Date
______
Department Chair Date Dean Date
OTHER APPROVALS (AS NEEDED)
______
Signature Date Signature Date
FOR USE BY RESEARCH SUPPORT SERVICES
______
Announcement Number CFDA #
Underrecovery of Indirect Costs: ______
______
RSS Proposal Log Number Date / ______
Received by Date
______
Reviewed by Date
______
Approved by Date