Fillable Pcf-form Proposal Certification Form

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Pcf-form Proposal Certification Form

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Page 1
Solicitation Number:
Submission Type: Proposal Classification:
New Research
Other Sponsored Activity
(Banner Index)
Instruction
Emphasis Area:
Natural Resources Biomedical/Health
Energy Supporting Capabilities/Facilities
Materials and Manufacturing
Budget:
rev: 8-2018 * Cost Share Form and Separate Cost Share Budget Required
+ SubAward Documentation Required
Research Office Use Only:
Submission Method
Special Instructions:
In:
Out:
Investigator(s) are required
to complete this form and
submit along with a copy of
the proposal and
guidelinesto the Research
Office 7 days PRIOR to the
deadline.
From: ____________
To: ______________
CFDA: _____________
PI and co-PI Information
Full Name
Department
Employee ID
Submission Due Date:
Originating Sponsor:
Immediate Sponsor:
Proposal Processing
Number:
Internal Proposal
Certification Form
Amount to SubAward+
(if applicable)
Project Dates:
Additional Funding:
Proposal Title:
Total Direct Costs
F&A
Total Requested
Amount to Cost Share*
(if applicable)
Page 2
Yes No
Have you and all other investigators completed PI training?
Does sponsor policy prohibit or restrict F&A? If yes, attach policy.
Does sponsor policy require mandatory cost share (matching funds)? If yes, attach policy.
Do you have cost share? If yes, cost share form and budget required.
Do you have sub-awards? Documentation required.
Do you have consultants? Documentation required.
Does project have intellectual property potiental?
Do you propose faculty release time? If yes, approval by Department Head: _____________________
Do you need additional space? If yes, VCAA approval: ____________________________
Will this project require building alterations? If yes, Director of Facilities approval: _______________
Do you propose curriculum change or academic credit?
Compliance:
Human Subjects. Insitutional Review Board review/approval required. __________________
Biohazard. Environmental Health and Safety Director approval is required. ___________
Animal Compliance. Research Office approval required ______________
Recombinant DNA/Bloodborne Pathogens. Environmental Health and Safety Director approval is required.
Terms and Conditions
Director of Sponsored Programs
Vice Chancellor for Research
Date
Signature
Dean
co-PI
Department Head
Dean
Name
Signature
In accordance with the Montana Tech Conflict of Interest Policy regarding financial disclosure, by signing below I certify that I am in
compliance with federal, state, and University regulations regarding Conflict of Interest. I/We certify that staff time of indviduals
involved, faculty release time, space, equipment, facilities, hazardous material disposal, alterations, cost sharing funds, etc. required for
this project are available or are part of the direct costs requested in the proposal. I/We certify all information on this form is correct.
I/We understand my/our responsibilities as Principal Investigator and Co-Principal Investigator(s).
Date
co-PI
Department Head
Date
Signature
Name
Proposal Approvals:
Name
Signature
Date
PI
Department Head
Dean
Name Signature Date
co-PI
Department Head
Dean
Budget Form
Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative
Contract Professional
Hourly Wages
Graduate Salary
Benefits
Contracted Services
General Supplies
Communications
Travel
Rent
Utilities
Repairs & Maintenance Gen.
Equipment
Other
Total Direct Costs
F&A Rate:
Total Requested
Project Dates: _______________
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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Page 3
Supplement #1 To be used for additional co-PIs
Terms and Conditions
In accordance with the Montana Tech Conflict of Interest Policy regarding financial disclosure, by signing below I
certify that I am in compliance with federal, state, and University regulations regarding Conflict of Interest.
I/We certify that staff time of indviduals involved, faculty release time, space, equipment, facilities, hazardous
material disposal, alterations, cost sharing funds, etc. required for this project are available or are part of the direct
costs requrested in the proposal. I/We certify all information on this form is correct. I/We understand my/our
responsibilities as Principal Investigator and Co-Principal Investigator(s).
Proposal Approvals:
Name
Signature
Date
PI
Department Head
Dean
Name
Signature
Date
co-PI
Department Head
Dean
Dean
Name
Signature
Date
co-PI
Department Head
Name
Department
Employee ID Number
Department Head
Dean
Name
Signature
Date
co-PI
Principal Investigator : PI Department:
Sponsor Name: Proposal Number:
Project Title:
% Time
Non-
Personnel
Expenses
Faculty
Staff Time
and Fringe
($)
Funding Source
or Banner Index
% Time
Non-
Personnel
Expenses
Faculty
Staff Time
and Fringe
($)
Funding Source
or Banner Index
Total Department $ Grand Total
Total College $ Cost Share Investments $
Total VCR $
Total Other $ 8/1/2018
Employee Name or Non-
Personnel Expense Description
Department Authorized
Signature and Date
Cost Share Agreement Form
Sub-Total: Department
Department Commitments:
College Commitments:
Employee Name
College Authorized Signature
and Date
VCR Signature
Sub-Total: College
Vice Chacncellor for Research Commitments:
VCR Commitment $
Description/Source
Other:
Unrecovered F&A
Contributed F&A
3rd Party In-Kind
Other
0
0
0
0
$ 0
$ 0
$ 0
$ 0
$ 0
Budget Form
Year 1 Year 2 Year 3 Year 4 Year 5 Cumulative
Contract Professional
Hourly Wages
Graduate Salary
Benefits
Contracted Services
General Supplies
Communications
Travel
Rent
Utilities
Repairs & Maintenance Gen.
Equipment
Other
Total Direct Costs
F&A Rate:
Total Requested
Project Dates: _______________
Cost Share Budget Form
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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Pcf-form Proposal Certification Form

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Completed 4 March 2020

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