1737 West Polk Street (MC 672)
304 Administrative Office Building
Chicago, IL60612
Phone: 312.996.2862 Fax: 312.996.9005 / REQUEST FOR PI AWARD TRANSFER/RELINQUISHMENT
(For UIC Internal Approvals Only)
Principal Investigator:
/Date:
Administering Department:
/PAF#:
Department Project Contact:
/Dept. Project Contact Email and Phone Number:
Project Period Dates:
/Agency and Award No. (e.g. NIH R01 GM12345):
AWARD RELINQUISHMENT/TRANSFER INFORMATION(1a) Date PI will leave UIC: / **/**/** / (1b) Date that award will be relinquished at UIC: / **/**/**
(2)Does this award involve the use of: / Human Subjects? / Yes / No
Animal Subjects? / Yes / No
(3) Does this award involve cost-sharing? / Yes / No
(4)Does this award involve subcontracts? / Yes / No
If yes, has the PI/dept notified the subcontractor(s) of the pending transfer? / Yes / No
Name of the subcontractor(s):
(5)Will any award-acquired equipment be transferred to the new institution? If yes, please see sponsored project equipment transfer and complete the required form: / Yes / No
(6)Will any portion of this project need to be subcontracted back to UIC by the new institution (e.g, to fund graduate students completing degrees, to cover work that will not be transferred?) / Yes / No
(7)Has the PI discussed/notified the funding agency (Program Officer and Grants Management Specialist) of the intended transfer? If yes, please provide any relevant details in the Comments section below. If no, please contact Program Officerand Grants Management Specialist to obtain prior approval. / Yes / No
(8)Name of the new institution where the PI intends to transfer the award : ______
(9)Name and contact information for OSP contact at new institution: (name, address, phone, email)
______
(10)Have any inventions been disclosed under the award, or does the award involve use of patented material or material made available to the University under a Material Transfer Agreement? / Yes / No
(11)Have all required progress reports (quarterly/annual) been filed with the funding agency? / Yes / No
(12) Estimated budget amount to be transferred to new institution (including F&A): / $
Comments:
SIGNATURES DESIGNATING APPROVAL FOR THE AWARD RELINQUISHMENT/TRANSFER:
PI
/Date:
Department Chair:
/Date:
Dean:
/Date:
Authorized Institutional Official
/Date:
Submit this completed form along with agency specific transfer form(s) if applicable to Office of Research Services whenever the Principal Investigator is transferring to another institution and planning to take an award from a federal or non-federal funding agency with him/her before the project end date of a grant, contract or cooperative agreement from those agencies.COMPLETED FORM DUE TO ORS AT LEAST 45 DAYS PRIOR TO RELINQUISHMENT/TRANSFER.
This form is for internal approvals only. Do not send form to sponsor.
‘
ORS FORM - Version 1.02 (2/15)