Florida Atlantic University Division of Research

Florida Atlantic University Division of Research

SubawardApplicationForm–Full Version

I. Contact Information:

OrganizationName:
Address:
City,StateandZipCode:
EIN Number:
DUNS Number:
Has yourorganization conductedbusinesswithFAU before? / □ Yes□ No
If no, please provideW9 formandcontact name andemailaddress ofperson that is able to provide ACH information. (FAUrequirespayments to be made by ACH)
Name: ______Email: ______
ProjectTitle
PI/ ProjectManager / Co-PIName
College/Dept.or Company / College/Dept.or Company
E-mail / E-mail
Phone / Phone
Contact Name
College/Dept.or Company / Email
Phone / Fax

1. ProposalInformation:

A.ResearchSubjects

Does theprojectincludeHumanSubjects?
(If yes, please provide approval.) / □Yes □No
Does theproject includeAnimalSubjects?
(If yes, please provide approval.) / □Yes □No
Does the project include use of Embryonic Stem Cells?
(If yes, please provide approval.) / □Yes □No

B.EnvironmentalHealthSafetyResearchSafeguards

Does the project involve EH&S compliance considerations (e.g. infectious agents, hazardous chemicals, recombinant DNA, radioactive materials, nano materials, boating and diving)? / □ Yes □ No

C.ExportControls

Does the project include work covered by ITAR or EAR? / □Yes □No
Will this project involve participation of foreign nationals in the U.S. (“deemed export”) or transfer of goods, services, information or technology abroad, or travel outside of the U.S.? / □Yes □No

D.Financial Conflict of Interest

If required by the sponsor, does your organization have a compliant financial conflict of interest policy? / □Yes □No
Is there a potential or identified conflict of interest? / □ Yes □No

III.RequiredDocumentation:

□ / ScopeofWork/Proposal
□ / IRB or IACUC approval (if applicable)
□ / FinancialProfile Documents attached:
Most recentlyauditedFinancialStatements(if applicable)
AuditReport(ifapplicable)
IndirectCostRateAgreement(for Federalprojects)
Systemfor AwardManagement(SAM) Registration Confirmation
W-9 (if organizationhasneverconducted business withFAU)

V. Financial Profile Information:

Does your organization have a financial management system that provides records that can identify the source and application of funds for award supported activities? / □Yes □No
Does your organization’s financial management system provide for the control and accountability of project funds, property and other assets? / □Yes □No
Does your organization havepolicies or procedures that address:

• Pay rates and benefits?
• Time and attendance?
• Leave?
• Travel?
• Purchasing?
• Discrimination?

/ □Yes □No
□Yes □No
□Yes □No
□Yes □No
□Yes □No
□Yes □No
Does your organization have controls to prevent expenditure of funds in excess of approved, budget amounts? / □Yes □No
Doesyour organization’sprocurementsystemallowfor freeandopencompetitionandeliminateor reduceconflictof interestintheprocurementprocess? / □Yes □No
Has your organization implemented any new system or has there been a change to any existing system within the last 2 years? (e.g. accounting, information, management, etc.)? If yes, please explain: / □Yes □No
Does your organization have procedures which provide assurance that consistent treatment is applied in the distribution of charges to all grants? / □Yes □No
Does your organization have its financial statements reviewed by an independent public accounting firm? Ifyes, pleaseprovideacopyofthemostcurrentfiscal year financial statements or website link: / □Yes□No
Is your organization exempt from Uniform Guidance, 2 CFR Part 200 Subpart F-Single/Program-Specific Audit? If yes, please state reason:
Expendedlessthan$500,000 of federalfundsfor thesubjectfiscalyear
For Profitentity
Foreign(non-U.S.) entity
__Other: ______/ □Yes □No
If required, has your organization completed an audit underUniform Guidance, 2 CFR Part 200 Subpart-F-Single/Program Audit for the most recent fiscal year? If yes, please provide a copy of the most current fiscal year audit or provide website link: / □Yes □No
FOR FEDERAL OR FEDERAL-FLOW PROJECTS:
Does your organization have a federally-negotiated indirect cost rate? If yes, please provide a copy of the most recent rate agreement or link to agreement: / □Yes □No
Does your organization have experience receiving and managing federal awards? If yes, please list previous federal sponsors: / □Yes □No
If this subaward is funded by a Federal or Federal Flow-through Source, is subrecipient registered in SAM? If yes, please provide confirmation of registration.
SAM Expiration Date: ______/ □Yes □No

VI. Signatures

Authorized Official:

Signatureof AuthorizedOfficial:
Name(printed): / Date:
Title: / Phone:

Principal Investigator:

BysignaturethePrincipalInvestigator(PI)offers thefollowingassurances:(1) thattheinformationsubmittedwithintheapplicationistrue,completeandaccuratetothebestofthePI’sknowledge;(2) thatanyfalse,fictitious,or fraudulentstatementsor claimsmaysubjectthePIto criminal,civil,or administrativepenalties;and(3) thatthePIagreestoacceptresponsibilityforthescientificconductoftheprojectandtoprovidetherequiredprogressreportsifagrantisawardedasa resultoftheapplication.

PrincipalInvestigator– Signature
(originalor electronic signatureonly; no “per” signature)

PrincipalInvestigator– PrintedName /
Date