Step I: Complete and turn in this page (Page 1) to Provost Council prior to your proposal preparation and Step II.

1. General Proposal Information

Project Working Title: Click here to enter text.

Principal Investigator/Project Director: Click here to enter text.

Phone: Click here to enter text. Fax: Click here to enter text. E-mail: Click here to enter text.

Department/School: Click here to enter text.

Other Belmont Faculty Involved: Click here to enter text.

Sponsor/Agency: Click here to enter text.

Grant Program Name (If applicable): Click here to enter text.

Sponsor Deadline: Click here to enter text. Receipt Date or Postmarked Date

(Note: To “check” any box in this application, double click on square checkbox and select “checked”)

Total Project Period: Begin Date: Click here to enter text. End Date: Click here to enter text.

Type of Project: Research Training/Instruction Public Service Event Other

Type of Submission: New Continuation Revised

Does this proposal involve the development of a new minor or major? Yes No

Estimated Average Annual Funding Requested: $ Click here to enter text.

F&A (Indirect Costs) Allowed? Yes No

Cost/Sharing Match Required? Yes No

2. Briefly explain how this project fits into the mission of the University (please do not exceed space provided).

Click here to enter text.

3. Provide a brief project summary that includes all colleges, programs and faculty involved with and/or impacted by the project (please do not exceed space provided).

Click here to enter text.

STEP II: After Step I, complete this page (Page 2) and attach your proposal narrative and detailed budget, and submit these three things to your Department Chair or Associate Dean.

4. Summary Budget

Requested Costs: / Total for Entire Project / Year 1 or Current Year / Belmont University Cost Sharing/Match
Direct Costs / $ Click here to enter text. / $ Click here to enter text. / $ Click here to enter text.
F&A Costs / $ Click here to enter text. / $ Click here to enter text. / $ Click here to enter text.
Total Request / $ Click here to enter text. / $ Click here to enter text. / $ Click here to enter text.

5. Special Review Checklist

Will your project involve human subjects? Yes No If yes, then notify the IRB (www.belmont.edu/irb)

Additional Requirements/Considerations: If yes to any of the following, please explain:

a)  Is faculty release time requested? Yes No Click here to enter text.

b)  Is extra compensation to Belmont Yes No Click here to enter text.

faculty or staff requested?

c)  Will this proposal require new full- Yes No Click here to enter text.

time staff and/or faculty to be hired?

d)  Is more space required? Yes No Click here to enter text.

e)  Will students be hired from these Yes No Click here to enter text.

grant funds?

f)  Is there a significant financial interest Yes No Click here to enter text.

(as defined by University FCOI policy) of the investigators and/or family members that would reasonably appear to be

affected by the project proposed?

g)  Any subcontract or consortia agreements? Yes No Click here to enter text.

If yes, is Belmont the primary contractor or subcontractor? (circle or highlight one)

6. University Approvals (obtain in sequence)

The Principal investigator or Project Director is responsible for securing his/her Department Chair’s and Dean’s signatures. After the Dean signs off on the routing form, please submit the entire proposal form and attachments to the Office of Grants & Scholarship, which will interface with the Provost.

Investigator Certification: My signature below certifies that 1) I am not delinquent on any federal debt; 2) I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from current transactions by a federal department or agency; 3) I have not and will not lobby any federal agency on behalf of this award; and 4) I have completed and submitted a Significant Financial Interest Disclosure Form if applying for a Public Health Service/NIH or NSF award.

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Principal Investigator/Project Director Date

Administrative Approvals: The academic review of the proposal is the responsibility of the Department or School. These signatures indicate that the signers are familiar with the proposal and are responsible for all commitments in the proposal as they relate to their areas, space, personnel, or budget.

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Department Chair/Associate Dean Date

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Dean/Director/VP Date

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Associate Provost Date

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Provost Date

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Rev. 07/12/2013