FormApprovedThrough8/31/2015OMBNo.0925-0001

DepartmentofHealthandHumanServices
PublicHealthServices
GrantApplication
Donotexceedcharacterlengthrestrictionsindicated. / LEAVEBLANK—FORPHSUSEONLY.
Type / Activity / Number
ReviewGroup / Formerly
Council/Board(Month,Year) / DateReceived
  1. TITLEOFPROJECT(Donotexceed81characters,includingspacesandpunctuation.)

2. RESPONSETOSPECIFICREQUESTFORAPPLICATIONSORPROGRAMANNOUNCEMENTORSOLICITATIONNOYES
(If“Yes,”statenumberandtitle)
Number:Title:
3.PROGRAMDIRECTOR/PRINCIPALINVESTIGATOR
3a.NAME(Last,first,middle) / 3b.DEGREE(S) / 3h. eRACommonsUserName
3c.POSITIONTITLE / 3d.MAILINGADDRESS(Street,city,state,zipcode)
E-MAILADDRESS:
3e.DEPARTMENT,SERVICE,LABORATORY,OREQUIVALENT
3f. MAJORSUBDIVISION
3g.TELEPHONEANDFAX(Areacode,numberandextension)
TEL:FAX:
4. HUMANSUBJECTSRESEARCH
NoYes / 4a.ResearchExemptIf“Yes,”ExemptionNo.
NoYes
4b.Federal-WideAssuranceNo. / 4c.ClinicalTrial
NoYes / 4d.NIH-definedPhaseIIIClinicalTrial
NoYes
5.VERTEBRATEANIMALSNoYes / 5a.AnimalWelfareAssuranceNo.
6. DATESOFPROPOSEDPERIODOF SUPPORT(month,day,year—MM/DD/YY) / 7. COSTSREQUESTEDFORINITIAL BUDGETPERIOD / 8. COSTSREQUESTEDFORPROPOSED PERIODOFSUPPORT
From / Through / 7a.DirectCosts($) / 7b.TotalCosts($) / 8a.Direct Costs($) / 8b.TotalCosts($)
9. APPLICANTORGANIZATION Name
Address / 10.TYPEOF ORGANIZATION
Public:FederalStateLocal
Private: PrivateNonprofit
For-profit:GeneralSmallBusiness
Woman-ownedSociallyandEconomicallyDisadvantaged
11.ENTITYIDENTIFICATIONNUMBER
DUNSNO. / Cong.District
12.ADMINISTRATIVEOFFICIALTOBENOTIFIEDIFAWARDISMADE Name
Title
Address
Tel:FAX: E-Mail: / 13.OFFICIALSIGNINGFORAPPLICANTORGANIZATION Name
Title
Address
Tel:FAX: E-Mail:
14.APPLICANT ORGANIZATION CERTIFICATION ANDACCEPTANCE:I certifythat thestatementshereinaretrue, complete andaccurate tothebestofmyknowledge,and accepttheobligationtocomply withPublicHealthServicestermsand conditions ifa grant isawarded asa resultof this application.Iamawarethat anyfalse, fictitious, orfraudulent statementsorclaimsmaysubjectmeto criminal,civil,oradministrativepenalties. / SIGNATUREOFOFFICIALNAMEDIN13.
(Inink.“Per”signaturenotacceptable.) / DATE

DETAILEDBUDGETFORINITIALBUDGETPERIOD DIRECTCOSTSONLY

FROMTHROUGH

04/01/201711/30/2017

ListPERSONNEL(Applicantorganizationonly)

UseCal,Acad,orSummertoEnterMonthsDevotedtoProject

EnterDollarAmountsRequested(omitcents)forSalaryRequestedandFringeBenefits

NAME / ROLEON PROJECT / Cal. Mnths / Acad. Mnths / Summer
Mnths / INST.BASE SALARY / SALARY REQUESTED / FRINGE BENEFITS / TOTAL
SUBTOTALS
CONSULTANTCOSTS
EQUIPME46NT(Itemize)
SUPPLIES(Itemizebycategory)
TRAVEL
INPATIENTCARECOSTS
OUTPATIENTCARECOSTS
ALTERATIONSANDRENOVATIONS(Itemizebycategory)
OTHEREXPENSES(Itemizebycategory)
CONSORTIUM/CONTRACTUALCOSTS / DIRECTCOSTS
SUBTOTALDIRECTCOSTS FOR INITIAL BUDGET PERIOD(Item7a,FacePage) / $
CONSORTIUM/CONTRACTUALCOSTS / FACILITIESANDADMINISTRATIVECOSTS
TOTALDIRECT COSTS FOR INITIALBUDGET PERIOD / $

DETAILEDBUDGETFORSECONDBUDGETPERIOD DIRECTCOSTSONLY

FROMTHROUGH

12/1/1709/30/18

ListPERSONNEL(Applicantorganizationonly)

UseCal,Acad,orSummertoEnterMonthsDevotedtoProject

EnterDollarAmountsRequested(omitcents)forSalaryRequestedandFringeBenefits

NAME / ROLEON PROJECT / Cal. Mnths / Acad. Mnths / Summer
Mnths / INST.BASE SALARY / SALARY REQUESTED / FRINGE BENEFITS / TOTAL
SUBTOTALS
CONSULTANTCOSTS
EQUIPMENT(Itemize)
SUPPLIES(Itemizebycategory)
TRAVEL
INPATIENTCARECOSTS
OUTPATIENTCARECOSTS
ALTERATIONSANDRENOVATIONS(Itemizebycategory)
OTHEREXPENSES(Itemizebycategory)
CONSORTIUM/CONTRACTUALCOSTS / DIRECTCOSTS
SUBTOTALDIRECTCOSTS FOR INITIAL BUDGET PERIOD(Item7a,FacePage) / $
CONSORTIUM/CONTRACTUALCOSTS / FACILITIESANDADMINISTRATIVECOSTS
TOTALDIRECT COSTS FOR INITIALBUDGET PERIOD

PHS398(Rev.08/12ApprovedThrough8/31/2015)OMBNo.0925-0001

ProgramDirector/PrincipalInvestigator(Last,First,Middle):

BUDGETJUSTIFICATION

PERSONNEL

HPTNScholarSalarySupplement:

TheHPTNScholarsalarysupplement requestsfundingtocover

Werequest SalarySupplementfor18months:$

TRAVEL

TravelExpenses:WearerequestingtravelfundsfortravelstoHPTNScholarsrelatedmeetings,conferences,

andvisitingmentorshipwith(YourHPTNMentor)at_(Institution)

.Travelfundsrequested

asoutlinedbelowincluderoundtripairfare,hotel,meals,groundtransportation,andtravel-relatedincidentals.

Werequestatotaltravelbudgetforattendanceofthemeetingsasoutlinedbelow:$

HPTNANNUALMEETINGS(2MEETINGS,4DAYSEACH):$.

AttendanceoftheseannualHPTNmeetingsarerequirementoftheHPTNScholarsProgram.Estimatesare basedontraveltoWashington,DCwhichwasthepreviouslocationofthismeeting.

Travelfrom toWashingtonDC(RT):$/tripx2trips=$Hotel:$/dayx4daysx2trips=$

Meals:$/dayx4daysx2trips=$

Groundtransportation:$ /tripx2trip=$Travelcostsincidentals:$/tripx2trip=$

HPTNSCHOLARSRETREAT(1MEETING,3DAYS):$.

AttendanceofthisHPTNMid-yearmeetingisarequirementoftheHPTNScholarsProgram.Estimatesare basedontraveltoSeattle,WAwhichwasthepreviouslocationofthismeeting.

Travelfrom to (RT):$x1trip=$Hotel:$/dayx3days=$

Meals:$/dayx3days=$

Groundtransportation:$/trip=$Travelcostsincidentals:$/trip=$

Anyotherrelevantconferenceduringtheprogram(IAS,USCA,etc.):$

Attendancetothe conferencewillbebasedon invitationtopresentonHPTN- relatedanalysishe/shesubmitsaspartoftheHPTNScholarsProgram.

Travelfrom to (RT):$x1trip=$Hotel:$/dayx3days=$

Meals:$/dayx3days=$

Groundtransportation:$/trip=$Travelcostsincidentals:$/trip=$

OMBNo.0925-0001/0002(Rev.08/12ApprovedThrough8/31/2015)Page ContinuationFormatPage

BIOGRAPHICALSKETCH

ProvidethefollowinginformationfortheSenior/keypersonnelandothersignificantcontributorsintheorderlistedonFormPage2.

Followthisformatforeachperson.DONOTEXCEEDFOURPAGES.

NAME

eRACOMMONSUSERNAME(credential,e.g.,agencylogin)

POSITIONTITLE

EDUCATION/TRAINING(Beginwithbaccalaureateorotherinitialprofessionaleducation,suchasnursing,includepostdoctoraltrainingand residencytrainingifapplicable.)

INSTITUTIONANDLOCATION / DEGREE
(ifapplicable) / MM/YY / FIELDOFSTUDY

A.PersonalStatement

B.PositionsandHonors

PositionsandEmployment

OMBNo.0925-0001/0002(Rev.8/12ApprovedThrough8/31/2015)Page 5BiographicalSketchFormatPage

OtherExperienceandProfessionalMemberships

Honors

C.SelectedPeer-reviewedPublications(SelectedfromXXpeer-reviewedpublications)

Mostrelevanttothecurrentapplication

Additionalrecentpublicationsofimportancetothefield(inchronologicalorder)

D.ResearchSupport

OngoingResearchSupport

CompletedResearchSupport

ForNewandRenewalApplications(PHS398)–DONOTSUBMITUNLESSREQUESTED

PHS 398 OTHER SUPPORT

Provideactiveandpendingsupportforallsenior/keypersonnel.OtherSupportincludesallfinancialresources,whetherFederal,non-Federal, commercialorinstitutional,availablein directsupportofanindividual'sresearchendeavors,includingbutnotlimitedtoresearchgrants, cooperativeagreements,contracts,and/orinstitutionalawards.Trainingawards,prizes,orgiftsdonotneedto beincluded.

Thereisno"formpage"forothersupport.Informationonothersupportshouldbeprovidedintheformatshownbelow,usingcontinuationpagesas necessary.Includetheprincipalinvestigator'snameat thetopandnumberconsecutivelywiththerestoftheapplication.Thesamplebelowis intendedtoprovideguidanceregardingthetypeandextentofinformationrequested.

Forinstructionsandinformationpertainingtotheuseofandpolicyforothersupport,seeOtherSupportintheSupplementalInstructions,PartIII,

Policies,Assurances,Definitions,andOtherInformation.

Effortdevotedto projectsmustbemeasuredusingpersonmonths.Indicatecalendar,academic,and/orsummermonthsassociatedwitheachproject.

NAME OF INDIVIDUAL

ACTIVE/PENDING

Project Number (Principal Investigator) Source

Title of Project (or Subproject)

The major goals of this project are… OVERLAP (summarized for each individual)

Format

Dates of Approved/Proposed Project

Annual DirectCosts

Samples

Person Months (Cal/Academic/ Summer)

NAME OF INESTIGATOR

ACTIVE

PENDING

OVERLAP

NAME OF INESTIGATOR

NONE

NAME OF INESTIGATOR

ACTIVE

OVERLAP

NAME OF INESTIGATOR

ACTIVE

OVERLAP:

ProgramDirector/PrincipalInvestigator(Last,First,Middle):

CHECKLIST

TYPEOFAPPLICATION(Checkallthatapply.)

NEWapplication.(ThisapplicationisbeingsubmittedtothePHSforthefirsttime.)

RESUBMISSIONofapplicationnumber:

(Thisapplicationreplacesapriorunfundedversionofanew,renewal,orrevisionapplication.)

RENEWALofgrantnumber:

(Thisapplicationistoextendafundedgrantbeyonditscurrentprojectperiod.)

REVISIONto grantnumber:

(Thisapplicationisforadditionalfundstosupplementacurrentlyfundedgrant.)

CHANGEofprogramdirector/principalinvestigator.Nameof formerprogramdirector/principalinvestigator:CHANGEof GranteeInstitution. Nameofformerinstitution:

FOREIGNapplicationDomesticGrantwithforeigninvolvementListCountry(ies) Involved:

INVENTIONSANDPATENTS(Renewalappl.only)NoYes

If“Yes,”PreviouslyreportedNotpreviouslyreported

1.PROGRAMINCOME(Seeinstructions.)

Allapplicationsmustindicatewhetherprogramincomeisanticipatedduringtheperiod(s)for whichgrantsupportisrequest.Ifprogramincomeis anticipated,usetheformatbelowtoreflecttheamountandsource(s).

BudgetPeriod / AnticipatedAmount / Source(s)

2. ASSURANCES/CERTIFICATIONS (Seeinstructions.)

InsigningtheapplicationFacePage,theauthorizedorganizationalrepresentativeagreestocomplywiththepolicies,assurancesand/orcertifications listedintheapplicationinstructionswhenapplicable.Descriptionsofindividualassurances/certificationsareprovidedinPartIIIandlistedinPartI,4.1 underItem14.If unabletocertifycompliance,whereapplicable,provideanexplanationandplaceitafterthispage.

3.FACILITIESAND ADMINSTRATIVECOSTS(FA)/INDIRECTCOSTS.Seespecificinstructions.

DHHSAgreementdated: xx/xx/20xxNoFacilitiesAndAdministrativeCostsRequested. DHHSAgreementbeingnegotiatedwith RegionalOffice.

NoDHHSAgreement,butrateestablishedwithDate

CALCULATION*(Theentiregrantapplication,includingtheChecklist,willbereproducedandprovidedtopeerreviewersasconfidentialinformation.)

a.Initialbudgetperiod: / Amountofbase$ / xRateapplied / %=F&Acosts / $
b.02year / Amountofbase$ / xRateapplied / %=F&Acosts / $
c.03year / Amountofbase$ / xRateapplied / %=F&Acosts / $
d.04year / Amountofbase$ / xRateapplied / %=F&Acosts / $
e.05year / Amountofbase$ / xRateapplied / %=F&Acosts / $

*Checkappropriatebox(es):

TOTALF&ACosts$

SalaryandwagesbaseModifiedtotaldirectcostbaseOtherbase(Explain)

Off-site,otherspecialrate,ormorethanonerateinvolved(Explain)

Explanation(Attachseparatesheet,ifnecessary.):

4.DISCLOSUREPERMISSIONSTATEMENT:If thisapplicationdoesnotresultinanaward,istheGovernmentpermittedtodisclosethetitleof yourproposedproject,andthename,address,telephonenumberande-mailaddressoftheofficialsigningfortheapplicantorganization,to

organizationsthatmaybeinterestedincontactingyouforfurtherinformation(e.g.,possiblecollaborations,investment)?YesNo

PHS398(Rev.08/12ApprovedThrough8/31/2015)OMBNo.0925-0001

Page ChecklistFormPage

Attachment1:DetailedBudgetAssumptionsforIllustrativePurposesforNewScholars

Salary / 01April–3001Dec2017–30Total
November2017Sept2018(10April2017-Sept
(8months)months)2018

NameTBD Scholarin

Role

training

Inst.BaseSalary$

SalaryRequest%x mos$$$

Fringe%$$$

Total$$$

Travel

HPTNMeetings(2)atStartandat12months(4daystoinclude1 daymentorprogramretreat)

Airfare:NewYork--DC / $/RT / $ / $ / $
PerDiem:DC / $/Day / $ / $ / $
Incidentaltravelcosts / $ / $
(communications,etc.) / $/trip / $
AirportTransfers / $/trip / $ / $ / $

HIV/AIDSNationalMeeting(N=1;3days)

Airfare:NewYork--Atlanta / $/RT / $ / $
PerDiem:Atlanta Incidentaltravelcosts (communications,etc.) / $/day
$/trip / $
$ / $
$
AirportTransfers / $/trip / $ / $

HPTNScholarMid-YearMeeting(N=1;3days)

Airfare:NewYork—Seattle / $/RT / $ / $
PerDiem:Seattle Incidentaltravelcosts (communications,etc.) / $/day
$/trip / $
$ / $
$
AirportTransfers / $/trip / $ / $
Meetingswithoutoftownmentor(4tripsof5dayseach)–ifapplicable
Airfare:NewYork--DC$/RT / $ / $ / $
PerDiem:DC$/day / $ / $ / $
Incidentaltravelcosts
(communications,etc.)$/trip / $ / $ / $
AirportTransfers$/trip / $ / $ / $
OtherDirectCosts–ifapplicable
Telecommunicationcostsformonthlycalls / $ / $ / $
Photocopyingofkeypreventionarticles,manuals,etc / $ / $ / $
Generalofficesupplies:books;software / $ / $ / $
TotalDirectCosts / $ / $ / $
IndirectCosts(avg.30%) / $ / $ / $
TOTALCOSTS / $ / $ / $

Notes:The mid-year meeting takes place in Seattle and the Annual Meeting in DC each year.