UIC Proposal Approval Form (PAF)/ORS KC Version 2.0 01/23/2018

UIC Proposal Approval Form (PAF)/ORS KC Version 2.0 01/23/2018

Proposal Approval Form (PAF)KC Version 2.0 (01/23/2018)
Office of Research Services (ORS)
1737 West Polk Street (MC 672)
304 Administrative Office Building
Chicago, IL 60612
Phone: 312-996-2862 / For ORS Use Only
IP #: ______Previous Institution #:______
Date: / /20 Time In: ______
Assigned Reviewer Initials:______
COI Yes No Grants.gov #: ______
Budget Review Yes No Initials ______
Reviewer Signature ______Date: ______

I.  General Information

Sponsor Deadline: Date Time (CST): / Date of: Please SelectPostmarkReceiptTarget
Electronic Submission by ORS: Yes No / If yes, Please SelectGrants.govAssistFastlaneDODProposal CentralAHAOther Electronic SystemHRSADOJ-GMSOther, if other please specify :
Do any investigators on this proposal have a joint appointment with the Jesse Brown VA Medical Center?
·  Yes If yes, and submitting to NIH, attach your Supplemental Joint UIC/VA Appointment Form
·  No
If signature is required, please indicate how you would like to receive the document. Please SelectElectronic signed documentHard Copy (picked up at ORS)

II. UIC Project Contact (e.g. Business Manager, Program Coordinator)

Name: / Email: / Phone: / Mail Code:

III.  Administering Unit (Complete ONLY if different from the PI’s home unit)

Administering Unit Name: / Org. Code:
Contact Name: / Email: / Phone:

IV.  Principal Investigator/Project Personnel

1.  Name: / UIN Number: / Home Unit and Org. Code:
Email: / Phone:
Project Personnel / Project Role / UIN / Home Unit and Org. Code
2.  / Please Select PICo-InvestigatorKey Personnel , eg Mentor, OSC
3.  / Please Select PICo-InvestigatorKey Personnel
4.  / Please Select PICo-InvestigatorKey Personnel
5.  / Please Select PICo-InvestigatorKey Personnel
6.  / Please Select PICo-InvestigatorKey Personnel

For additional Principal Investigator/Project Personnel, please go to PAF Continuation Page.

V.  Project Title (If this project is a Task Order/Protocol related to a Master Agreement, provide Institution #:)

VI.  Sponsor Information (Organization directly funding UIC - no acronyms or abbreviations)

Full Name of Sponsoring Organization:
Street Mailing Address Suite/Room (No PO Box):
/ Sponsor Contact Name:
City: / State: / Zip: / Email:
Country: / Phone: / Fax:
Is Sponsor a federal agency? Yes No If Yes provide CFDA Program Number
·  If No, is "Sponsor's" originating source of funds from a federal agency (federal flow-through)? Yes No
·  If Yes, specify federal agency name: and CFDA Program Number:
Does this proposal include subaward(s)? Yes No
Funding Opportunity # or Opportunity Name if no # available:

VII.  Project Information

Type of Proposal: / Please SelectNewRenewalResubmissionSupplement/AmendmentTask Order Previous Institutional number:
Type of Activity: / Please SelectResearch - BasicResearch - AppliedResearch - DevelopmentClinical TrialFellowshipInstructionOther Sponsored ActivityPublic Service
Limited Submission / Yes No If Yes, attach a copy of authorization received from RDS

VIII.  Budget

Year One or Current Year (mm/dd/yy format):
From: To: / Total Project Period (mm/dd/yy format):
From: To:
Budget / Year 1 or Current Year / Total for Entire Project / On-Site Off-Site
Does budget include tuition remission? Yes No
Direct Cost / $ / $
Facilities & Admin. (ICR) / $ / %* / $ / %*
Total Request / $ / $
*If F&A rate is not the UIC Federally Negotiated Rates, provide published sponsor documentation or F&A Waiver Form
Cost Sharing – Answer ALL questions below. If the answer to any question is ‘yes’ you must submit a cost share budget along with this proposal and a cost share letter from the individual with the authority to commit the resource. All cost sharing committed in the proposal must be clearly documented. Sponsor-imposed caps (i.e. salary, F&A rate, fringe benefit rate) are not considered cost sharing.
Type / Yes/No / Description
1.  Salary (Donated Effort) / Yes No / Proposed effort not reimbursed by the sponsor. Sponsor-imposed salary cap is not considered cost sharing.
2.  Non-Salary / Yes No / Supplies, travel, non-capitalized equipment, etc.
3.  Unrecovered F&A / Yes No / Sponsor approval is required to use unrecovered F&A as cost sharing. Sponsor-imposed F&A rate cap is not considered cost sharing.
4.  Third Party / Yes No / Non-UIC parties (e.g. subawardees, vendors, consultants) proposing to contribute effort, services, or goods to the project which are not reimbursed by the sponsor. This does not include individuals with no measurable effort.
5.  Other / Yes No / Explain:
*If the answer is Yes to any of the above, then there is committed cost sharing in this proposal. If so, is cost sharing required by the sponsor? Yes (Mandatory) No (Voluntary)

IX.  Distribution of College and Department F&A Allocation

College/Unit Name / Org. Code / % F&A
1. / %
2. / %
3. / %
4. / %
5. / %
6. / %

X.  Compliance

This project uses or involves: / Yes/No / Clearance required:
Human Subjects Research / Yes No / Pending (For all New and Competitive Renewal Applications)
IRB #:
Human Specimens and/or Data / Yes No / Pending OPRS Determination of Whether an Activity Represents Humans Subjects Research
Research Protocol #:
Animals / Yes No / Pending (For all New and Competitive Renewal Applications)
ACC #:
Recombinant DNA or Infectious Agents/Toxins / Yes No / IBC #:
Human Embryonic Stem Cells / Yes No / ESCRO #:
UIC Hospital, Clinics or MRI Center / Yes No / UIC Hospital, Clinics or MRI Center Approval:
Signature ______Date ______

XI.  Conflict of Interest Certification

All Investigators regardless of the funding source and senior/key research personnel on HHS/PHS/NIH sponsored research must complete this section.
In accordance with the University Policy on Conflict of Commitment and Interest, significant financial interests (SFIs) must be disclosed to the COI Office at the proposal stage and within 30 days of any newly acquired or discovered SFIs or changes in the reported SFIs on awarded grants.
If an Investigator or key research personnel responds “Yes” to the question below, then you must contact the Conflict of Interest Office at or (312-996-4070) to complete additional forms for disclosure and management. For additional resources, see FAQs and Guidelines on the disclosure and management of Significant Financial Interests.
·  At present or in the 12 months prior to this disclosure, do you or your family members have a significant financial interest (SFI) with the research sponsor or any subcontract recipient? Or have any other relationships or sponsored or reimbursed travel that may present a potential Financial Conflict of Interest with this research?
For completion by all Investigators If you check ‘Yes” notify PI and Contact the COI Office
1.  Role: PI / Name: / No Yes
2.  Role: Please Select / Name: / No Yes
3.  Role: Please Select / Name: / No Yes
4.  Role: Please Select / Name: / No Yes
5.  Role: Please Select / Name: / No Yes
6.  Role: Please Select / Name: / No Yes

XII.  Proposal Approval

A.  Investigator(s)
The Investigator(s) certifies the following:
i.  that the information submitted within the application is true, complete and accurate to the best of their knowledge;
ii.  that any false, fictitious, or fraudulent statements or claims may subject the Investigator(s) to criminal, civil, or administrative penalties;
iii.  agrees 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 the application;
iv.  that you are not currently debarred, suspended or ineligible to receive federal or non-federal funds;
v.  that, as required by the University, you are current in your financial conflict of interest training, disclosures of sponsored or reimbursed travel and disclosures of known significant financial interests (and those of spouse or domestic partner, parents, siblings and children) that might reasonably be related to your University responsibilities; and, when required under sponsor regulation.
vi.  The PI further certifies that all Senior/Key Personnel including subrecipient(s) proposed under this submission are current in such disclosures of known significant financial interests.
1.  Role: PI / Name: / Signature: / Date :
2.  Role: Please Select / Name: / Signature: / Date :
3.  Role: Please Select / Name: / Signature: / Date :
4.  Role: Please Select / Name: / Signature: / Date :
5.  Role: Please Select / Name: / Signature: / Date :
6.  Role: Please Select / Name: / Signature: / Date :
B.  Department/Unit Head(s)
The Department Chair/Unit Head has reviewed and approved the project and any resource commitments, and certifies that the research can be conducted safely and in compliance with federal and state laws. If the Principal Investigator is the department or unit head, the individual the PI reports to must sign.
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
C.  Schools or College Dean(s), except for College of Engineering, College of Medicine, College of Pharmacy, School of Public Health and College of Liberal Arts and Sciences
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
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