Proposal No.
BROOKHAVEN NATIONAL LABORATORY
PROPOSAL INFORMATION QUESTIONNAIRE (PIQ)
STRATEGIC PARTNERSHIP PROJECTS (SPP)
DEPARTMENT OF HOMELAND SECURITY (DHS)
I.GENERAL INFORMATION - Section 309 of the Homeland Security Act of 2002, Public Law 107-296 (6 U.SlC. 189) and the MOA dated February 28, 2003 between the Department of Homeland Security and the U.S. Department of Energy provide the legal authority for entering into SPPprojects funded by DHS.
1. Proposal Title:
2. Name of Principal Investigator/Department:
3.Proposed Period of Performance:
4.Proposed Funding:Year 1 - $Year 4 - $
Year 2 - $Year 5 - $
Year 3 - $TOTAL - $
- Has amount of indirect funds attributed to LDRD been identified in the budget? Y/N
- Is this project related to an earlier Laboratory Directed R&D (LDRD) Program Y/N
If yes, provide LDRD number and title
- Does the work call for safeguards and security requirements beyond that normally
Provided by DOE for the conduct of its own activities? Y/N
If yes, identify these costs in the proposal.
5.Brief Description of Work:
6.DHS Sponsor:
City, State Zip
7.Sponsor Contact (Name, Phone, & Email):
8.Is proposal in response to a Request for Proposal (RFP)? Y/N
9.Is proposal in response to a Request for Application (RFA) or Broad
Agency Announcement? If yes, attach copy of RFA or BAA Y/N
II. CLASSIFICATION REVIEW10.a.Will classified information or materials, export controlled information
(ECI) or unclassified controlled nuclear information (UCNI) be used, produced or referenced in this work? / Y/N
b. Are Special Nuclear Materials (SNM) involved (U235, U233, Pu, Np237,
Am241, Am243)? / Y/N
c. Has DOE-CH Form F 470.1 Contract Security Classification Specifications (CSCS) for Establishing a Security Interest, previously been filed for this work with the BNL Facility Security Manager?
If the answer to a. thru c. is YES, a completed BNL Security Interest Checklist, PIQ and copy of the proposal will be sent to the BNL Facility Security Manager by the Budget Officer. The BNL Facility Security Manager will determine if a DOE-CH Form F 470.1 will be required. / Y/N
11. Operational Security (OPSEC) Considerations:
a. Could this project result in information or technology that could, if made public:
(1) Have a significant adverse impact on U.S. national or economic security? (Benefit a foreign company or government) / Y/N
(2) Along with other published information, lead to sensitive or classified information? / Y/N
b. If the answer to either (1) or (2) above is Yes, will non-U.S. citizens have access to the resulting information or technology?
/ Y/N
c. Does this work involve a computer to process sensitive data or information? / Y/N
d. Is this Intelligence or Intelligence-related Work? / Y/N
If Yes, provide the name of the contact at the Sponsoring Intelligence
Agency
e. Will the results of this work be restricted from publication or release and
will foreign nationals participate in the work or access the information? / Y/N
If any answer to a. thru e. is YES, the Business Development and Analysis Office will send a copy of the PIQ and a copy of the proposal to the BNL OPSEC Working Group Chair. The BNL OPSEC Chair will determine if additional actions are required.
III.INTELLECTUAL DATA
12.Does this work involve a BSA-owned invention or one in which
BSA intends to elect title, or one in which the proposer has a
financial interest?(Y/N)
If “Yes”, provide complete details in attachment to PIQ.
13.Are there any restrictions on publication or distribution of
data/information pertaining to this proposal?(Y/N)
If “Yes”, state restriction
IV.PROJECT SPECIFICS
14.Is sponsor funding the purchase of capital equipment? Y/N
If “Yes”, provide cost and description of equipment
15.Will outside consultants or subcontractors be required for any part of this work? Y/N
If yes, what special capabilities are needed?
16. Is any major construction or modification to BNL facilities involved? Y/N
If yes, provide description:
17.Are there any special circumstances, unusual space, equipment, or support
requirements? Y/N
If “Yes”, provide details:
18.Are Biohazards involved in the proposed work? Y/N
If "Yes", please attach a current copy of approval from the Institutional
Biosafety Committee.
19.Does this project involve human subjects or animal research? Y/N
Human Subjects is defined as “A living individual from whom an investigator
obtains either (1) data about that individual through intervention or interaction
with the individual, or (2) identifiable, private information about that individual”
If yes, attach copy of the current Institutional Review Board (IRB) or Institutional
Animal Care and Use Committee approval as applicable.
20.a. Does proposed work require travel to a foreign country? Y/N
If “Yes”, identify foreign country:
b. Does proposed work involve interaction with non-domestic entities Y/N
21.Are there any special ESH requirements applicable to this work that are not
addressed under current BNL policies and procedures? Y/N
22.Is NEPA review and approval form included? Y/N
23.DHS is among the list of organizations that has received DOE’s approval for
waiving the Full Cost Recovery. Has a waiver been attached? Y/NY
24.Is another DOE facility involved in the proposed work? Y/N
If “Yes”, identify facility
25. Does the proposal provide sufficient funding for disposal of equipment, appropriate decommissioning of the research space and any project waste, if applicable, when
the experiment is complete? Y/N
26. Additional remarks pertaining to any of the above items:
V.APPROVALS
Principal InvestigatorDate
BNL’s budget for this proposal has been developed in accordance with DOE Order 522.1 and BNL’s approved financial accounting practices
Budget OfficerDate
______
Laboratory OfficialDate
______Date
DOE Field Office Official
1 (02/2015)