UIC Proposal Approval Form (PAF)/ORS Version 3.010/25/2018

Proposal Approval Form (PAF)Version 3.0(10/25/2018)
Office of Research Services (ORS)
1737 West Polk Street (MC 672)
304 Administrative Office Building
Chicago, IL 60612
Phone: 312-996-2862 / For ORS Use Only
Proposal #: ______
Date: / /20
Assigned Reviewer Initials:______
COI Yes No
Budget Review Yes No Initials ______
Reviewer Signature ______Date: ______

I.Proposal Details

Proposal Type: / Please SelectNewContinuationRenewalSupplement/Amendment Previous Institutional number:
Lead Unit: / Org. Code:
Activity Type: / Please SelectResearch - BasicResearch - AppliedResearch - DevelopmentSponsored InstructionOther Sponsored ActivityFellowshipClinical Trial
Project Dates: / From: To:
Project Title:
Sponsor:
Prime Sponsor (if applicable):

II.Sponsor & Program Information

Sponsor Deadline: DateTime (CST): / Sponsor Deadline Type:Please SelectHardTarget
Submission By: Please SelectCentral OfficeUnit / Submission Type:Please SelectElectronicUS Mail
Sponsor Mailing Address:
/ Sponsor Contact Name:
City: / State: / Zip: / Email:
Country: / Phone: / Fax:
Notice of Opportunity: / Please SelectFederal Grant SolicitationFederal Contract SolicitationUnsolicitedNon-Federal SolicitationInternal
Opportunity ID:
Temporary Application ID (if applicable [e.g. NSF Temp ID, ASSIST Application Identifier]):

III.Key Personnel

1.PIName: / UIN: / Home Unit and Org. Code:
Email: / Phone:
Project Personnel / Project Role / UIN / Home Unit and Org. Code
2. / Please Select Principal InvestigatorCo-Principal InvestigatorCo-InvestigatorKey Person
3. / Please Select Principal InvestigatorCo-Principal InvestigatorCo-InvestigatorKey Person
4. / Please Select Principal InvestigatorCo-Principal InvestigatorCo-InvestigatorKey Person
5. / Please Select Principal InvestigatorCo-Principal InvestigatorCo-InvestigatorKey Person
6. / Please Select Principal InvestigatorCo-Principal InvestigatorCo-InvestigatorKey Person

* For additional Principal Investigator/Project Personnel, please go to PAF Continuation Page.

IV.UIC Project Contact (e.g. Business Manager, Program Coordinator)

Name: / Email: / Phone:

V.F&A Allocation

College/Unit Name / Org. Code / F&A Percentage
%
%
%
%
%
%

VI.Compliance

Type / Yes/No / Approval Status
Human Subjects / Yes No / Pending (For all New and Competitive Renewal Applications)
IRB Protocol #:
Animal Subjects / Yes No / Pending (For all New and Competitive Renewal Applications)
ACC Protocol #:
UIC Hospital, Clinics or MRI Center / Yes No / UIC Hospital, Clinics or MRI Center Approval:
Signature ______Date ______
Biological Safety (including Select Agents and rDNA) / Yes No / IBC Protocol #:
Human Embryonic Stem Cells / Yes No / ESCRO #:

VII.Budget

Budget Period / Period Start Date / Period End Date / Direct Cost / F&A Cost / Total Sponsor Cost
1 / $ / $ / $
2 / $ / $ / $
3 / $ / $ / $
4 / $ / $ / $
5 / $ / $ / $
TOTAL / $ / $ / $
  1. Cost Sharing

Source Type / Description / Yes/No
  1. Contributed Effort (Donated Effort/Salary)
/ Does proposal include Donated Effort/Salary? (i.e. Proposed effort not reimbursed by the sponsor. A sponsor-imposed salary cap is not considered cost sharing.) / Yes No
  1. Cost Share F&A (Including Unrecovered)
/ Does proposal include Cost Share F&A/Unrecovered F&A? (Note: Sponsor approval is required to use unrecovered F&A as cost sharing. A sponsor-imposed F&A rate cap is not considered cost sharing.) / Yes No
  1. Hard Match
/ Does proposal include Hard Match (Non-Salary)cost sharing? (i.e. Supplies, travel, non-capitalized equipment, etc.) / Yes No
  1. Third Party Entity
/ Does proposal include Third Party cost sharing? (i.e. Non-UIC parties (e.g. subawardees, vendors, consultants) proposing to contribute effort, services, or goods to the project which are not reimbursed by the sponsor. This does not include individuals with no measurable effort.) / Yes No
  1. Other In-Kind
/ Explain: / Yes No
If the answer is Yes to any of the above, then there is committed cost sharing in this proposal. If so,is cost sharing required by the sponsor? Yes (Mandatory) No (Voluntary)
  1. Supplemental Information

  1. Indirect Cost Rate
/
  1. Additional Compliance Attributes

Rate: / % / Human Specimens or Data: / Yes No
Basis: / Please Select MTDCTDCOther / Export Control / Yes No
Location: / Please Select On CampusOff Campus / Export Control Description (if applicable):
Explanation: / Please Select Full RateSponsor Limited RateWaiver Rate
Comments:
*If F&A rate is not the UIC Federally Negotiated Ratesprovide published sponsor documentation or F&A Waiver Form
  1. Additional Project Approvals and Project Characteristics

Limited Submission: / Yes No (If Yes, attach a copy of authorization received from RDS)
Program Income Anticipated: / Yes No
SBIR/STTR Solicitation: / Yes No
Training Grant: / Yes No
Tuition Remission: / Yes No
VA Joint Appointment: / Yes No(If yes and submitting to NIH, attach your Memorandum of Understanding For Individuals with Joint University/Veteran’s Affairs Medical Center Appointments)

X.Conflict of Interest Certification

All Investigators regardless of the funding source and senior/key research personnel on HHS/PHS/NIH sponsored research must complete this section.
In accordance with the UniversityPolicy on Conflict of Commitment and Interest, significant financial interests (SFIs) must be disclosed to the COI Office at the proposal stage and within 30 days of any newly acquired or discovered SFIs or changes in the reported SFIs on awarded grants.
If an Investigator or key research personnel responds “Yes” to the question below, then you must contact theConflict of Interest Office at or (312-996-4070) to complete additional forms for disclosure and management. For additional resources, see FAQs and Guidelines on the disclosure and management of Significant Financial Interests.
  • At present or in the 12 months prior to this disclosure, do you or your family members have a significant financial interest (SFI) with the research sponsor or any subcontract recipient? Or have any other relationships or sponsored or reimbursed travel that may present a potential Financial Conflict of Interest with this research?
For completion by all Investigators If you check ‘Yes” notify PI and Contact the COI Office
  1. Role: PI
/ Name: / No Yes
  1. Role: Please Select
/ Name: / No Yes
  1. Role: Please Select
/ Name: / No Yes
  1. Role: Please Select
/ Name: / No Yes
  1. Role: Please Select
/ Name: / No Yes
  1. Role: Please Select
/ Name: / No Yes

XI.Proposal Approval

  1. Investigator(s)
By certifying this proposal, you are certifying that:
(1)the information submitted herein is true, complete and accurate to the best of your knowledge
(2)any false, fictitious, or fraudulent statements or claims may subject you to criminal, civil or administrative penalties
(3)you agree to accept responsibility for the scientific conduct of the project and to provide progress reports
(4)you are current in your disclosures of known significant financial and/or familial conflicts that might reasonably appear to be affected by the proposed research
(5)when required under sponsor regulation, you further ensure that you are current in such disclosures of known significant financial and/or familial interests
(6)to your knowledge, you have disclosed any organizational conflicts of interest (including government or sponsor consulting activities) that could be reasonably related to this sponsored project.
Any investigator with a significant financial interests (SFI) or organizational conflict related to the proposed project or any subcontract recipient must disclose the SFI and/or the organizational COI to the University COI Office at the time of proposal and identify the conflict is related to this project. Failure to disclose and manage conflicts may result in violation of federal regulations and could delay award execution or jeopardize the award. Questions, .
  1. Role: PI
/ Name: / Signature: / Date :
  1. Role: Please Select
/ Name: / Signature: / Date :
  1. Role: Please Select
/ Name: / Signature: / Date :
  1. Role: Please Select
/ Name: / Signature: / Date :
  1. Role: Please Select
/ Name: / Signature: / Date :
  1. Role:Please Select
/ Name: / Signature: / Date :
  1. Department/Unit Head(s)
The Department Head, Unit Head, or an authorized delegate of either, approves: (1) that the proposal aligns with the mission of the unit; (2) the qualifications of the researcher; (3) the availability of necessary unit space and resources; (4) that the level of mentorship is appropriate (if applicable); (5) commitments of unit cost sharing; and (6) the unit’s commitment to support the proposal if funded. No person may sign this proposal form as both a Researcher and the Unit Head.
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
  1. Schools or College Dean(s), except for College of Engineering, College of Medicine, College of Pharmacy, School of Public Health and College of Liberal Arts and Sciences
The Dean or Director approves this proposal and if applicable any of the following: (1) commitments of college or institute cost sharing; (2) the variance in the federally negotiated Facilities and Administrative rate.
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
Name: / Signature: / Date :
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