Fillable Proposal Summary Form (Marine Biological Laboratory)

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Proposal Summary Form (Marine Biological Laboratory)

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The Proposal Summary Form (Marine Biological Laboratory) form is 5 pages long and contains:

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  • 73 check-boxes
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Proposal Summary Form
Please complete and email this form to the Office of Sponsored Programs (OSP):
10 business days PRIOR to submission deadline with a link to the Program Announcement, the Work Scope or
Project Description and the Budget & Budget Justification
Full/completed proposal is due to OSP 5 business days PRIOR
to the submission deadline -
PLEASE NOTE: Proposals sent in a timely manner to OSP will help assure a successful submission. Failure to meet the deadline
may jeopardize the on-time submission of the proposal. Late submissions may be subject to an incomplete review which puts both
the PI and MBL at risk. PLAN AHEAD AND SUBMIT EARLY!
1. KEY PERSONNEL DATA:
First Name
Last Name
MBL Center/Program
Phone Number
Email
PI:
2. PROJECT INFORMATION:
Proposal Type:
Check one: Grant
Contract
Cooperative Agreement
Check one (if applicable):
Collaborative Proposal – Lead institution:
Subaward to MBL – Lead Institution:
This Action is: Check one:
New Transfer from:
Resubmission – Original Proposal:
Supplement to award:
Competing renewal to award #:
Check one:
Electronic submission via:
Hard copy submission via:
Title:
Sponsoring Agency (include issuing
organization ) ex: NIH/NIDDK
Project Period
(Begin & End Dates):
Announcement Number
(FOA #, PA# or RFA#)
Proposal Due Date
Pre-Proposal ONLY
Receipt Date:
entered by OSP
Conflict of Interest Completed:
entered by OSP
1
Marine Biological Laboratory
Proposal Summary Form
Page 1 of 3
v8.19.2019LH
Marine Biological Laboratory
Proposal Summary Form
Page 2 of 3
v8.19.2019
Are there any Subcontracts to be issued by the Marine Biological Laboratory?
Yes No
If yes, please fill in the following information:
Institution
Contact Information
3. BUDGET INFORMATION AND INTELLECTUAL PROPERTY ISSUES:
a. Is the F&A Rate requested less than the MBL federally negotiated rate?
Yes No
If yes, please explain and include the rate: (NOTE: requires DDR approval; DF as FYI only)
b. Is Cost Sharing proposed for this project?
Yes No
If yes, please fill in the following information: (NOTE: requires both DF and DDR approvals)
c. Does this proposal include any proprietary information the MBL should protect? Yes No
If yes, please indicate applicable sections of the proposal:
4. REGULATORY ISSUES:
Please mark all that apply. If already approved, give date & forward copy of approval
letter.
Approval
Date
Approval
Date
Recombinant (rDNA) & Synthetic Nucleic Acid Molecules
Laboratory Animal Care (requires IACUC Approval)
Infectious, Parasitic or Other Biohazardous Agents/Organisms
Human Research (requires IRB Approval)
Select Agents and Toxins (includes exempt quantities)
Export Controls (ITARS/EARS) (OSP Approval)
Human Subject Materials (human/non-human primate blood,
body fluid, cell lines, fixed/unfixed tissue or Other Potentially
Infectious Materials (OPIM) ) *may also require IRB Approval
Radioactive materials or radiation producing
equipment (notify MBL Biosafety Officer)
5. ADDITIONAL REQUIREMENTS NOT REQUESTED IN THE PROPOSAL BUDGET:
Please mark all that apply and briefly describe (NOTE: requires DDR approval; COO as FYI only)
Requirement
Description
Fabricated Equipment
Additional Space (include square feet )
Alterations to current space
Graduate or Undergraduate students
Type
Source
Amount
Equipment(total proposed project period)
Other Direct Costs
Salary & Fringe: Key Personnel
F & A Indirect Costs
Total
REQUIRES IBC APPROVAL:
REQUIRES ADDITIONAL APPROVALS:
6. CERTIFICATIONS AND APPROVALS:
PRINCIPAL INVESTIGATOR(S):
1. that the information submitted
within the application referenced here by Project Title
and Deadline or Submission Date is accurate;
2. and acknowledge
that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil,
or administrative penalties;
3. and agree to accept responsibility for
the scientific conduct of the project and to provide
all required reports if a grant is awarded as a result of this application.
Certification of Conflict of Interest :
Marine Biological Laboratory
Proposal Summary Form
Page 3 of 3
v8.19.2019
1. that an annual Conflict of Interest (COI) form has been filed with the MBL
for myself and
all Key Personnel listed on this application;
2. and that if there are any changes
in the COI pursuant to this application, an updated COI will be
submitted prior to
the
expenditure of any federal funds awarded as a result of this application
I certify;
I also certify;
I do hereby certify that all of the information above is true, complete and
accurate to the best of my knowledge
PI APPROVAL
DIVISION DIRECTOR (DDR) APPROVAL (*for ANY of the following conditions)
_________________________________________________________________________________________________________________________________________
PI Signature Date
CENTER DIRECTOR (CD) APPROVAL (for Resident Scientists only)
_________________________________________________________________________________________________________________________________________
Center Director Signature Date
*ADDITIONAL APPROVALS AS REQUIRED
DIRECTOR OF FINANCE (DF) APPROVAL (*for COST SHARE only)
• if PI is Center Director, MBL Fellow, Adjunct or Research Scientist, MBL Course Director,
Admin/Other (Note: for DDR proposals approval of MBL Director is required)
• has under-recovery
• has cost share
• for additional requirements (fabricated equip,additional space,alterations to space,
graduate/undergraduate students
Date
Director of Finance Signature Date
Director Division of Research Signature
Date
DIVISION DIRECTOR (DDR) APPROVAL (*for ANY of the following conditions)
MBL Office of Sponsored Programs Signature
*FOR ALL PROPOSALS
MBL OFFICE OF SPONSORED PROGRAMS APPROVAL (*with FYI to DF or COO if applicable)
The proposed project is approved. It is consistent with the program objectives of the MBL. The
commitments for the project, including cost sharing/matching funds, are acceptable.
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COI_8.19.2019AC.docx | PAGE 1
MARINE BIOLOGICAL LABORATORY
CONFLICT OF INTEREST DISCLOSURE
Privileged Statement of Organizational Affiliations and Significant Financial Interests
(This disclosure must be submitted as indicated in Table 1 and at any time when the disclosure needs to be
updated)
For persons supported by Federally-sponsored activities, the form will be kept on file until three years
after the Federal award expires. If deemed necessary, the Director of Research Administration and
Sponsored Programs or the Director of Human Resources of the MBL may request additional information.
NAME: TITLE:
I. Current Organizational Affiliations: Including remunerated and
voluntary activities with government agencies,
industry and business, academic institutions, foundations, as a consultant, officer, owner, trustee, manager, or
teacher/professor. E.g. advisory board appointments, external teaching appointments, or adjunct status at
another institution. Please explain aspects of these activities that may be pertinent to your MBL
responsibilities. For example, provide the title of your position and/or description of your role, approximate
number of hours and/or days worked, if you are remunerated, and the level of your remuneration. If additional
space is needed, a Word document may be attached.
Organization
Type of Business
Remuneration
Effort –
Hrs/Year
1.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
2.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
3.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
4.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
II. Significant financial interests– List all organizations doing business with the MBL or whose business is
substantially related to your institutional responsibilities at the MBL from which you receive salary or other
compensation (royalties, licensing fees from patents, copyrights, etc.) greater than $5,000 for the preceding 12
months; or in which you have equity interests (stocks, options or other ownership interests) valued at $5,000 or
more; or 5% or more ownership interests. This includes aggregate financial interests of yourself and your
immediate family members (spouse, domestic partner, and/or dependent child/ren). Equity held via mutual funds,
pension funds, etc., are excluded. You may also exclude income from seminars, lectures, or teaching, and
service on advisory committees or review panels, for public (governmental) or non-profit entities.
COI_8.19.2019AC.docx | PAGE 2
Organization
Type of Business
Remuneration
Effort –
Hrs/Year
1.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
2.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
III.Additional Information:Briefly describe any other professional or personal circumstances or activities that in
your opinion might be reasonably construed as having a potential impact on your judgment about your official
MBL responsibilities.
____________________________________________________________________________________________
Please acknowledge the three statements below (if you are a course director or an adjunct scientist with
MBL, please acknowledge the first two statements only) and sign the form.
_____ I have read and understand this Policy and, to the best of my knowledge, I have no affiliation with any
organization or activity other than listed above that could be construed as constituting a conflict of interest with the
MBL, as defined in the MBL's Conflict of Interest Policy.
_____ If, during the course of the year, my affiliations or significant financial interests should change, I will notify
the Director of Sponsored Programs and Research Administration within 30 days or in any event before any new
research proposal is submitted or before any more funds are expended from an existing award.
_____ I certify that I have worked less than 52 days total in the past year on outside activities as specified in the
details above.
_____________________
Date
_____________________
________________________________________________
Signature
Reviewed By:
__________________________________________________
Director of Research Administration and Sponsored Programs Date
Date of Compliance Committee review: __________________________
Comments, if any action taken: _____________________________________________________________
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Proposal Summary Form (Marine Biological Laboratory)

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Completed 16 August 2020

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