GMO FORM GC-1

North Shore – LIJ Health System

GRANTS MANAGEMENT OFFICE

PROPOSAL ROUTING FORM

CATEGORY: NewResubmission Extension Supplement Renewal Other ______

Previous Project ID#, if applicable______

Principal Investigator/Program Manager: / Dept/Div:
PI Employee ID: / Facility:
Telephone: ()--Fax: ()-- e-mail: @
Name of Administrative Contact:
Telephone: ()--Fax: ()-- e-mail: @
Full Project Title:
Short Project Title:
Name of Sponsor:
Solicitation number and name:
Application Due Date: Has the deadline passed? YES NO
Name of Sponsor contact, if known:
Telephone: ()--Fax: ()-- e-mail: @
Is this a subcontract or subaward agreement? YES NO
If yes, name of flow-through sponsor:
CFDA No. (if known)

COMPLIANCE AND RESOURCES

Human Subjects YESNO

If Yes, IRB approval date (mm/dd/yy) //; or application pending .

Investigator(s) Research Registration Date //.

Clinical Trial? YESNO

Animal Use YESNO

If Yes, IACUC approval #; or application pending .

Radioactive Materials YESNO

If Yes, Radioactive clearance date //; or application pending .

Biohazardous Materials YESNO

If Yes, Biohazard safety approval date //; or application pending

Export Controls

Will this project involve foreign nationals? YESNO

Will this project involve foreign travel? YESNO

Will this project involve international shipping? YESNO

If yes, please attach brief description of international activities and/or foreign nationals involved.

Space: Does this project utilize existing space? YESNO

Will additional space be required for this project? YESNO

New Equipment YESNO

For new equipment, briefly describe and indicate additional space requirements

Conflict of Interest

  1. Have external financial (COI) disclosure forms for research been submitted to the COI in Research review process in the past calendar year for all key personnel on the project and have all external financial interests related to professional responsibilities been reviewed? YESNO

If yes, were any potential COIs identified and/or was a management plan requested? YESNO

If no, please attach updated conflict of interest disclosure.

  1. Please confirm that all key personnel on this project have reviewed their filed annual external financial (COI) disclosure form and that there have been no changes since the date of the last disclosure.

I confirm that there are no changes to the filed disclosure.

Changes are required and updated forms are attached.

PROPOSED BUDGET AND COST SHARE

EXPENSE CODE / CATEGORY / YEAR 1 / ALL YEARS / TOTAL COST SHARE
DIRECT COSTS:
60010 / SALARIES & WAGES
62960 / FRINGE BENEFITS @ 31%
62100 / TUITION PLAN REIMBURSEMENT
61000 / CONSULTANTS
63000 / SUPPLIES
66150 / TRAVEL
65550 / SUBCONTRACTS
65535 / OTHER PURCHASED SERVICES
65560 / PURCHASED SERVICES - AFFILIATES
66151 / PATIENT STUDIES
66060 / OTHER EXPENSE
66700 / EQUIPMENT
TOTAL DIRECT COSTS
IDC BASE
69015 / INDIRECT COST
IDC RATE USED: ______%
TOTAL COSTS

PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: I certify that the statements contained in this submission are true, complete and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this application.

PI/PD SignatureDate

By signing, you attest that you have reviewed and approved this grant application for scientific validity, clinical appropriateness, and use of your Department’s resources.

Department Chair / Center Head / Site Director SignatureDate

Secondary Chair , Center, or Site Approval (if needed)Date

Application approved for submission

Grants Management OfficeDate

APPLICATION RECEIPT DATE: COI Management Plan: YES NO

DATE SUBMITTED:INITIALS: