Extramural Routing Sheet (ERS)

Extramural Routing Sheet (ERS)

(FormerARS & Green Sheet – Institutional Use Only) (Effective 12-13-16)

Office for Sponsored Programs & Technology Transfer (OSPTT)

OSPTT Email address:

1. PROJECT INFORMATION

Principal Investigator Name:

Project Title:

Project Start Date :(mm/dd/yyyy) Project End Date: (mm/dd/yyyy)

Request for Proposal (RFP) Announcement#

(If nonfederal, please attach a copy of the announcement)

LSUHSC-S FACULTY PAID FROM THIS PROJECT–GRANT YR # 1 ONLY

Role in Project
(PI, Co-PI, Collaborator, Consultant) / Name / Department / Annual % Effort / Annual % Salary / Annual COI Completed / Signature
PI / Yes No
Choose an item. / Yes No
Choose an item. / Yes No
Choose an item. / Yes No
Choose an item. / Yes No

PI is REQUIRED to apply 20% effort/salary to project –ref: LSUHSC-S Policy on Grant Applications & Expenditures,

If PI is requesting exemption/salary waiver for salary support of less than 20%, exemption waiver must be approved in writing by
the Associate Dean for Research PRIOR to proposal submittal to funding agency. Please attach a copy of the waiver request email.

SPONSOR INFORMATION
Sponsor Name:
Sponsor Deadline Date (mm/dd/yyyy) PI has Rolling Submission Status
Electronic submission: OSPTT submit PI submit
Proposal Type- Select one
New- original submission of a full proposal
Supplement-request for additional funds during an approval project period to proposal #
Competing Continuation/Renewal- advances and extends the science of the initial grant - Federal ID #
Non-competing Continuation
Resubmission – For NIH, Federal ID #
Project Type- Select one
Basic Science Research
Clinical Research
Education
Equipment
Fellowship
Hospital Service
Instruction/Training
Translational Research
Other / Application Type- Select one
Grant
Consortium/Subcontract
Scientific Research Agreement
Other

1. PROJECT BUDGET

Cost Share Declaration
Is cost share or institutional match required by the sponsor, RFP, and/or solicitation? No Yes
If yes, please indicate the type of LSUHSC-S match:
Departmental Institutional
In cash: $
In kind: $
Matching Funds PeopleSoft Project Acct. #:
If matching resources are promised in this grant application, the PI must give a detailed list (personnel, supplies, equipment, or other funds) Please attach a detailed list of the matching resources for administration review and approval.
Approved:
______
Department Head/Date Associate Dean of Research/Date
(Department Match) (Institutional Match) / Will LSUHSC-S issue a subaward to an external entity?
No Yes
Number of years subrecipient participation
Subrecipient Institution:
Subrecipient PI name:
Grants office contact name and email:
Subrecipient IDC Rate:
Subrecipient Total Budget:
Will subrecipient personnel be responsible, along with the PI or CO-PI, for the design, conduct or reporting of the activities associated with this product? Yes No

1. COMPLIANCE

Boards and Committees (IACUC, IRB, IBC, RSC, RDRC)
Status / Approved Protocol Number
N/A / Pending / Approved
IACUC – Animal Studies
IRB – Human Subjects or Material
*If approved, please provide approval notice.
Biohazardous Materials (includes Recombinant DNA)
Radioactivity (includes chemicals and drugs)
Intellectual Property (IP) ( Current IP – Patents and Copyrights)

Will this project involve using currently filed patent applications, issued patents, and/or copyrights?

If unknown, choose No. Yes No

If yes, please provide USPTO reference number or LSUHSC-S Disclosure ID#

Other Compliance Topics – Complete ALL sections.
Is this a PHS (Federal Funds) or PHS flow-through proposal for LSUHSC-S to be a subcontractor? / Yes / No
Is proposal for STTR/SBIR (Small Business Technology Transfer/Small Business Innovation Research)? / Yes / No
Will any NON-EMPLOYEE foreign nationals by working on this project? If unknown, choose No. / Yes / No
Are you aware of any publication restrictions for LSU from the work on this project? / Yes / No
Are there plans to work with a scientist from an international country? Country / Yes / No
Does this involve a confidentiality agreement, material transfer agreement or proprietary information? / Yes / No
Has the LSUHSC-S PI, Co-PI, and KEY Personnel filed their COI forms within the past 12 months? / Yes / No
LSUHSCS Faculty Member Name:

ABSTRACT

LSUHSCS Faculty Member Name:

LSUHSCS Detailed Budget Form

Direct and Indirect Costs per Year – Year of

/ YR START DATE / YR END DATE

List PERSONNEL(ALLprojectpersonnel. Identifynon-LSUparticipants)

UseCalendarMonthstoEnterMonthsDevotedtoProject(example:25%=3mos,50%=6mos,75%=9mos;100%=12mos)

EnterDollarAmountsRequested(omitcents)forLSUHSCSBaseSalaryRequestedandFringeBenefits(exclude:RICPandSupplements)

NAME / Role of the PROJECT / Cal.
Mnths / % Sal. on Proj / INST.BASE
SALARY / SALARY
REQUESTED / FULL TIME FRINGEBENEFITS – 38% / TOTAL
LSUHSC Faculty PI
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
CONSORTIUM/CONTRACTUALCOSTS-TotalDirectCostsforYear of
CONSORTIUM/CONTRACTUALCOSTS-TotalIndirectCostsforYear of
Name of Consortium/Contractual Entity and Collaborator:
OTHER EXPENSES (Itemize by category)
SUBTOTAL Direct Costs for Year of DIRECT COSTS / $
TOTALIndirectCostsforYear of / (45%Federal/25%Other)INDIRECT COSTS
TOTALDIRECTANDINDIRECTCOSTSFORBUDGETPERIOD–Year of / $

LSUHSCS OSPTT Form 2016 ResearchAgreement

BudgetForms

LSUHSCS Faculty Member Name:

ENTIRE PROJECT START AND END DATES: TOTALBUDGET FORENTIREPROJECTPERIODFROM: Through: DirectandIndirectCosts

BUDGET CATEGORY
TOTALS / YR1BUDGETPERIOD / YR2BUDGET PERIOD / YR3BUDGET PERIOD / YR4BUDGET PERIOD / YR5BUDGET PERIOD
PERSONNEL:TotalSalary andfringebenefits. LSUHSCSPersonnelonly.
CONSULTANTCOSTS
(non-LSUHSCSpersonnel)
EQUIPMENT
SUPPLIES
TRAVEL
OTHEREXPENSES
SUBTOTALforLSUHSCSPROJECTDIRECTCOSTS
TOTALCONSORTIUMCOSTS
(DirectCosts+IndirectCosts)
SUBTOTALDIRECTCOSTS
- Per YR for PROJECT
INDIRECTCOSTS-PerYRforPROJECT
TOTAL COSTS - Per YR
(Direct Costs + Indirect Costs)
TOTALCOSTS FORENTIRE PROJECT PERIOD / $

LSUHSCS OSPTT Form 2016ResearchAgreement BudgetForms

LSUHSCS Faculty Member Name:

BUDGET JUSTIFICATION

Principal Investigator Certifications

Principal Investigator (PI) must read, sign, and obtain necessary authorizations for this form.

In compliance with LSUHSC-S’s Policies and Procedures regarding the conduct of externally funded activities, I certify the following:

1. I certify and attest that the information submitted within the accompanying application is original, true, complete, and accurate. 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.
2. I certify that I am neither presently debarred or suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in current transactions by any federal department or agency, and I am not delinquent on any federal debt.
3. I certify that I have read and understand LSUHSC-S’s Conflict of Interest Policy (COI) and that I will comply with the COI Policy and all conditions or restrictions imposed by LSUHSC-S to manage conflicts of interest or I will forfeit the award. I further certify that I will continue to comply with the COI policy throughout the life of this project and will complete a new Conflicts of Interest Disclosure form if circumstances arise (within 30 days of the change) that would warrant a positive disclosure on sponsored projects. (DHHS/ PHS Regulation 42 CFR Part 50 subpart F and 45 CFR part 94)
4. I certify as PI of this project that ALL LSUHSC-S research personnel involved in this project have a completed a COI Financial Disclosure as required by CM-23 and that the COI form is up-to-date and current. All LSUHSC-S research personnel involved in this project understand that any participating faculty, staff, or students (or their spouse or dependent children) having any significant financial interest such as royalty, equity, or any other payments (e.g., consulting, salary, etc.) in the sponsor or other entities having a significant financial interest in intellectual property, products or services which are the subject of the proposed project must disclose these relationships through the COI Xpress System.
5. If this application for funding is directly or indirectly from Public Health Services (PHS) agencies, I certify that I have read and understand LSUHSC-S’s Conflict of Interest Disclosure Form for PHS projects or make modifications if circumstances arise that would warrant further disclosure.
6. I certify that this work will be conducted in a drug free environment and that all articles resulting from DHHS funding have been entered into the National Library of Medicine’s Pubmed Central (NLM) in accordance with Division G, Title II, section 218 of PL 110-161 (Consolidation Appropriations Act, 2008), the NIH voluntary Public Access Policy (NOT-OD-08-033).
7. As the PI, I agree to abide by all provisions of the LSU System’s Bylaws, Policies, and Regulations regarding intellectual property and all proprietary research and I agree: (a) To disclose promptly, in writing, and agree to assign and hereby DO ASSIGN to LSUHSC-S all rights, in accordance with Chapter VII of the LSU System’s Bylaws and Regulations, and campus policy statement(s) as amended from time to time and (b) To execute all necessary papers and otherwise provide proper assistance, at LSUHSC-S’s expense, during, and subsequent to the period of my LSUHSC-S affiliation, to enable LSUHSC-S to obtain, maintain, or enforce for itself or its nominees, publications of proprietary research; patents, copyrights or other legal protection for any/all Intellectual Property; and (c) To prepare and maintain for LSUHSC-S adequate and current written records of all such LSUHSC-S proprietary research and Intellectual Property; and (d) Upon request, to deliver promptly to LSUHSC-S, copies of all written records referred to in Paragraph C above as well as all related memoranda, notes, records, plans or other documents.

Principal Investigator (PI)
Principal Investigator Name (Please Print or Type) / Principal Investigator Signature (Required) / Date
Authorizing Signatures
Department Chair/Director Name (Please Print or Type) / Department Chair/Director Signature / Date
Department Business Manager Name (Please Print or Type) / Department Business Manager Signature / Date

Co- Principal Investigator(Co-PI)

(Co-PI’s are defined as having thesame responsibility as a primary PI for the design, conduct or reporting of the activities associated with the project, without regard to paid status.).

Does this project include a Co-PI? Yes No If yes, Co-PI must sign certification form obtained at the following link:

1