AA

Form Approved Through 9/30/97

OMB No. 0925-0001

Department of Health and Human Services

Public Health Service

Grant Application

Follow instructions carefully.

Do not exceed character length restrictions indicated on sample.

LEAVE BLANK—FOR PHS USE ONLY.

Type

Activity

Number

Review Group Formerly

Council/Board (Month, Year)

Date Received

1. TITLE OF PROJECT (Do not exceed 56 characters, including spaces and punctuation.)

2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT NO YES (If "Yes," state number and title)

Number: Title:

3. PRINCIPLE INVESTIGATOR/PROGRAM DIRECTOR

3a. NAME (Last, first, middle)

3b. DEGREE(S)

3c. SOCIAL SECURITY NO.

3d. POSITION TITLE

3e. MAILING ADDRESS (Street, city, state, zip code)

 

 

 

 

 

EMAIL ADDRESS:

3f. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT

3g. MAJOR SUBDIVISION

3h. TELEPHONE AND FAX (Area code, number and extension)

TEL:

FAX:

4. HUMAN

SUBJECTS

No

Yes

4a. If "Yes," Exemption no.

or

IRB approval date

 

 

 

 

Full IRB or

Expedited

Review

4b. Assurance of

compliance no.

5. VERTABRATE

ANIMALS.

No

Yes

5a. If "Yes,"

IACUC approval

date

5b. Animal welfare

assurance no.

6. DATES OF PROPOSED PERIOD OF

SUPPORT (month, day, year—MM/DD/YY)

7. COSTS REQUESTED FOR INITIAL

BUDGET PERIOD

8. COSTS REQUESTED F0R PROPOSED PERIOD

OF SUPPORT

From

 

 

Through

7a. Direct Costs ($)

7b. Total Costs ($)

8a. Direct Costs ($)

8b. Total Costs ($)

9. APPLICANT ORGANIZATION

Name

Address

 

 

 

 

10. TYPE OF ORGANIZATION

Public: ® Federal State Local

Private: ® Private Nonprofit

Forprofit: ® General Small Business

11. ORGANIZATIONAL COMPONENT CODE

12. ENTITY IDENTIFICATION NUMBER

Congressional District

13. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE

Name

Title

Address

 

 

 

 

14. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION

Name

Title

Address

Telephone

FAX

 

E-Mail

Address

Phone

FAX

 

E-Mail

Address
  1. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE:

    2. I certify that the statements herein are true, complete and accurate to the best of my knowledge. I am aware that any false fictitious, or fraudulent statements or claims may subject to 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.

SIGNATURE OF PI / PD NAMED IN 3a (In ink.

"Per" signature not acceptable)

DATE
  • APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE:

    • I certify that the statements herein are true, complete and accurate to the bet of my knowledge, and accept the obligation to comply with Public Health Service terms and conditions if a grant is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil or administrative penalties.

    SIGNATURE OF PI / PD NAMED IN 3a. (In ink.

    "Per" signature not acceptable)

    DATE

    US 398 (Rev. 5/95)

    Face Page

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