Fillable Osp-transmittal-form New Fy17 Extended2 Transmittal form

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Osp-transmittal-form New Fy17 Extended2 Transmittal form

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The Osp-transmittal-form New Fy17 Extended2 Transmittal form form is 3 pages long and contains:

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  • 20 check-boxes
  • 24 other fields

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File type: PDF

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University of Mississippi Medical Center
Office of Research and Sponsored Programs
Continue to page 2
TRANSMITTAL FORM
Principal Department
Investigator
Proposal Proposal Type
Title
Activity Type
Sponsor
Award Type
Prime Sponsor
Due Date
BUDGET
Initial Period
Total Period
Start Date
End Date
Total Direct
Costs
Total F&A Costs
Total Requested
ASSURANCES
STATUS
PROTOCOL
NUMBER
ASSURANCES
STATUS
Animal Usage
Pathogenic
Microorganisms
Human
Subjects
Radioactive
Materials
Human/Other
primate tissue.
blood or cells
Laser
Recombinant
DNA
Fluoroscopy/CT
Do any investigators (or spouses and dependent children) involved in this project have an actual, real or
perceived conflict of interest that could reasonably appear to affect the research for which funding is sought or
whose interests would reasonably appear to be affected by the research?
1) Does this proposal include subcontracts?
Yes No
2) Does this proposal require matching funds?
Yes No
3) Is any voluntary cost-sharing proposed?
Yes No
If Yes to questions 2 or 3, enter amount
proposed:
Yes No
*
*
*If the sponsor or prime sponsor is NIH, please complete page 2.
Do you anticipate any foreign travel or collaborations? If yes, please
complete the export controls checklist.
Yess
No
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Print Form
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$ 0
$ 0
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NIH Certificate of Confidentiality Information
(Please complete only if NIH is the Sponsor or Prime Sponsor)
1)
Is the activity biomedical, behavorial, clinical, or other research?
Yes (Please proceed to question 2)
No (No further action is needed)
2) a. Does the research involve human subjects as defined by 45 CFR Part 46?
Yes**
No
b. Are you collecting or using human biospecimens?
c. Does the research involve the generation of individual level, human genomic data?
Yes**
No
d. Does the research involve de-identified or partially de-identified data?
Yes**
No
**If the answer to 2a, 2b, or 2c is "yes," the NIH
Certificate of Confidentiality (COC) Policy Applies, and
a COC is automatically issued as a term of the award.
The relevant NIH COC language must appear in the
informed consent document.
Continue to page 3
Yes**
No
Supplemental Information
Principal Investigator (Contact) Co-Principal Investigator
Division Chair*** Division Chair
Department Chair Department Chair
Dean**** Dean
*** Division Chair signatures are only required by the Department of Medicine
**** Dean signatures are only required for the School of Dentistry, School of Nursing and School of Health Related
Professions
Send completed and signed transmittal form, along with your complete application or draft contract
and detailed budget, to sponsoredprograms@umc.edu at least 5 business days prior to the sponsor’s
deadline.
PI assures that the information in the application is true, complete and accurate to the best of their
knowledge; acknowledges that any false, fictitious, or fraudulent statements or claims may subject the PI to
criminal, civil or administrative penalties; accepts responsibility for the scientific conduct of the project; and
agrees to provide progress reports are required by the sponsoring agency. Those signing below assure they
will abide by the rules and regulations of the federal government, sponsor and UMMC.
Indicate the core facilities this project will use
Core Facility 1
Core Facility 2
Core Facility 3
Indicate the keywords applicable to this project:
Primary Keyword
Keyword 2
Keyword 3
NSF Research Type
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Osp-transmittal-form New Fy17 Extended2 Transmittal form

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Completed 2 December 2019

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