Fill - Free fillable PEF 1 16 2019 RE Proposal Endorsement Form PDF form

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Revised1/16/2019

PROPOSALENDORSEMENTFORM(PEF)

TennesseeTechnologicalUniversity|OfficeofResearch|DerryberryHall,Room128

ProposalNo.

__________________

ProposedProje

ctPeriod:(MM/DD/YY)

 StartDate:_______________ |EndDate:

_______________

SubmissionType

NewProposal Supplement

Category:________________________

ProjectType:

___________________________

 GrantPersonnel:Personnelcodes:001‐PI;002‐Co‐PI

Anyindividualwho

holdsafull‐timeposition,suchastenured,tenuretrack,non‐tenuretrackresearch,directorofastate‐designatedCenterorUniversityCentermayserve

asaPrincipalInvestigator/ProjectDirectorforsponsoredactivities,andberesponsibleforacontractorgrant.Inaddition,anindividualwhoholdsthepositionofLecturer,

Instructor,Adjunct/Affiliate,Emeritus,orpart‐timefaculty(50%appointment)mayserveasaPrincipalInvestigator/ProjectDirectorforsponsoredactivitiesifheorshe

receivestheapprovalofhisorherchairanddeanasshownbytheirsignaturesonthisformandatenuredortenure‐trackresearchfacultyordirectorisnamedasco‐

investigatorontheproject.

 SeniorPersonnel:Personnelcode:007‐SeniorPersonnel

 OtherPerson

nel:Personnelcodes:003‐SupportPersonnel;004‐Bookkeeper;005‐SubrecipientMonitor

Thetablebelowshouldincludeallbudget‐relateditemsassubmittedtothefundingagency(i.e.,allrequestedfundsandrequiredcostshare).

Agency DepartmentalCost

Share

CenterCostShare TTUCostSha

re Otherand/or

In‐KindCostShare

1. TotalDirectCosts

2. ModifiedTotalDirectCosts

3. IndirectCostRateUsed

(Attach



supporting



documentation

ifdifferentfromTTUrate)



% %



4. TotalIndirectCosts Recovered Contributed Contributed Contributed Contributed

5. IndirectCostWaived

6. TotalProjectFunds

Costshare:Mandatory⃝orVoluntary⃝Ifcostshareismandatory,providedocumentation(e.g.,solicitation,emailfromprogramofficer,etc.).

ProposalTitle:

FundingAgency:

AgencyAddress:

ProgramOfficerInfo:

Name T‐Number Personnel

Code

College Dept. Center

Name T‐Number Personnel

Code

College Dept. Center

007

Name T‐Number Personnel

Code

College Dept. Center

Page 2 of 4

Proposal No.

__________________

Source of Center Cost Share

Source of TTU Cost Share

Source of Other and/or In-Kind Cost Share

Information Needed for Internal Tracking

In cases where waived or contributed indirect costs are not included in the table on page 1 because they were not allowed to be counted

toward the required cost share or no cost share is required, enter the amount of waived and contributed costs below:

Waived indirect costs

Contributed indirect costs

Compliance, Special Notices, Other: PI Initials (by initialing, PI verifies that the responses are true and accurate to the best of his/her knowledge)

Yes

MUST BE COMPLETED BY PI AND NOT A PROXY.

⃝ ⃝

Is extra pay requested? If yes, agency approval is required in writing.

⃝ ⃝

Does this proposal/project involve any restricted data, inventions, or proprietary information? If yes, contact the Office of

Research.

⃝ ⃝

Are subawards/consultants included in proposal? If so, list Subcontract Monitor in Grant Personnel.

⃝ ⃝

Will this project involve restrictions on dissemination of results? If yes, contact the Office of Research.

⃝ ⃝

Will this project include any export control restrictions? If yes, contact the Office of Research.

⃝ ⃝

Does this project involve human subjects? If yes, date application is submitted to TTU Institutional Review Board (IRB) for the

Protection of Human Subjects:___________

⃝ ⃝

Does this project involve animal care and use? If yes, date application is submitted to TTU Institutional Animal Care and Use

Committee (IACUC): ____________

⃝ ⃝

Does this project involve recombinant DNA molecules/infectious or biohazardous agents/radiological hazards?

If yes, contact Safety and Environmental Services at (931) 372-3524.

⃝ ⃝

Are computer purchases required? If yes, contact Information Technology Services at (931) 372-3387.

⃝ ⃝

Is equipment to be purchased? If yes, contact Purchasing at (931) 372-3491.

⃝ ⃝

Is space available for computer/equipment purchases? If no, contact Facilities at (931) 372-3227. Are additional project funds

requested to meet space, electrical, and/or maintenance needs? _____ No _____ Yes

⃝ ⃝

Have you been debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered

transactions by any federal department or agency? If yes, contact the Office of Research.

⃝ ⃝

Have you, within a three-year period preceding this proposal, been convicted of or had a civil judgment rendered against you

for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public

(federal, state or local) transaction or contract under a public transaction; violated federal or state antitrust statutes or

committed embezzlement, theft, forgery, bribery, falsified or destroyed records, made false statements, or received stolen

property? If yes, contact the Office of Research.

⃝ ⃝

Are you presently being indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state or local)

with commission of any of the offenses numerated in the question above? If yes, contact the Office of Research.

⃝ ⃝

Have you, within a three-year period preceding this application/proposal, had one or more public transactions (federal, state

or local) terminated for cause or default? If yes, contact the Office of Research.

⃝ ⃝

(Note: By marking “No” in this section, you certify that no lobbying has been done prior to the proposal being approved and

that no lobbying will be done after it has been approved. If yes, contact the Office of Research.) To the best of your

knowledge, have any lobbying activities been conducted relative to this proposal?

Source of Department Cost Share

Page 3 of 4

Note: The following four questions pertain to conflict of interest (Reference: Office of Research Conflict of Interest in Research Policy 735;

Code of Federal Regulations on Financial Conflict of Interest, 45 CFR Part 94.1; and Public Health Service Regulation 42 CFR Part 50.601).

Yes

⃝ ⃝

Are you or any member of your immediate family (spouse, parents, parents-in-law, siblings, children, other relatives living at

the same address as you, or reported as dependents on federal income tax forms) an officer, director, partner, trustee,

employee, advisory board member, or agent of the external organization funding this project or of any organization from

which goods and services will be obtained under this project?

⃝ ⃝

Do you or any immediate family member have any significant financial interest including, but not limited to, salary or other

payments for services (greater than $10,000 per year from sources other than the employee’s institution), equity interest

(greater than $10,000 in value or more than 5% of the ownership interest in a single entity), and intellectual property rights in

the external organization funding this project or of any organization from which goods and services will be obtained under this

project?

⃝ ⃝

Do you have any affiliation with the external organization that would diminish your ability to fulfill your paramount obligations

to your students, your colleagues, or the University; or have you involved any student in a proprietary capacity with the

external organization?

I certify that I DO ⃝ DO NOT ⃝ have any significant financial interests associated with the aforementioned proposal/project.

(If you do have a significant financial interest associated with this project, this interest must be disclosed in accordance with the University

and Office of Research policy.)

Comments: (e.g., Center Research Area) _________________________________________________________________________________

_________________

_________________________________________________________________________________________________

Certifications: By completing, signing and submitting this form, (1) the principal investigator(s)/coPI(s)/project director(s)

provide(s)

the certifications shown on the attached Certifications, Disclosures and Assurances Form and (2) the Center Director(s) certifies

that

the project addresses one or more goals of the Center.



The Principal Investigator(s)/co-PI(s)/Project Director(s) also certify that they are qualified to perform the work outlined in this

proposal.

I hereby certify that:

• The information submitted within the application is true, complete, and accurate to the best of my knowledge.

• I understand that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative

penalties.

• I will accept responsibility for the scientific conduct of the project within a drug-free, non-discriminatory workplace.

• I will provide, in a timely manner, the required reports to the sponsor if a grant is awarded as a result of the application.

Page 4 of 4

Proposal No.

__________________

APPROVALS

(In Sequence) MUST be signed by PI and Co-PIs, and appropriate administrators [Director(s), if applicable, Chairperson(s), and

Dean(s), and, if applicable, Research Liaison Off

icer] PRIOR to submission to Office of Research.

Principal Investigator Date

Co-PI/Senior Personnel/Support Personnel Date

ADMINISTRATIVE SIGNATURES REQUIRED

Note: If this project is funded, by signing this form, you are certifying that faculty members’ total commitment will not exceed

1 FTE combined with other duties.

Center Director(s) Date

Dean or Liaison Officer (of PIs/Co-PIs/Senior Personnel) Date

Center Director(s) Date

Dean or Liaison Officer (of PIs/Co-PIs/Senior Personnel) Date

Departmental Chairperson(s) (of PIs/Co-PIs/Senior Personnel) Date

Dean or Liaison Officer (of PIs/Co-PIs/Senior Personnel) Date

Departmental Chairperson(s) (of PIs/Co-PIs/Senior Personnel) Date

Office of Research Date

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