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Proposal-transmittal-form - Proposal transmittal form-GW COI

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Page 1 of 4
THE COLLEGE OF WOOSTER
Proposal Transmittal Form
PI/PD
DEPT. PHONE
INVESTIGATOR DEPT. PHONE
INVESTIGATOR DEPT. PHONE
INVESTIGATOR DEPT. PHONE
INVESTIGATOR DEPT. PHONE
INVESTIGATOR DEPT. PHONE
GRANTOR DEADLINE DATE
BUDGET REQUESTED
PERIOD START DATE END DATE DIRECT/$ INDIRECT/$ TOTAL
COST SHARE/$
(Details on Back)
1
ST
YEAR
$ $ $ $
2
ND
YEAR
$ $ $ $
3
RD
YEAR
$ $ $ $
4
TH
YEAR
$ $ $ $
5
TH
YEAR
$ $ $ $
6
TH
YEAR
$ $ $ $
7
TH
YEAR
$ $ $ $
TOTAL
$ $ $ $
Are you requesting funding for equipment or computers? [ ] NO [ ] YES If “yes”, please provide details on the back
Does the proposal involve creation of new staff positions? [ ] NO [ ] YES If “yes”, please consult the Dean for Faculty Development.
Does the proposal include Federal funds? [ ] NO [ ] YES
If “yes”, please attach a printout from the Excluded Parties List System that includes all
vendors named in the proposal. (See instructions.).
I certify that the statements made in the attached proposal, and on this form are
true and complete to the best of my knowledge. The budget is reasonable and
adequate for the project. I agree to comply with relevant Federal requirements
and the award terms and conditions if an award is made.
___________________________________________________
PI / PROJECT DIRECTOR DATE
I have discussed the attached proposal with the PI. Adequate space is available
or planned for the conduct of the project. The professional time allocations
described therein are realistic and within College guidelines.
___________________________________________________
DEPARTMENT CHAIR DATE
I have discussed the attached proposal with the PI and it meets all policy
requirements. Any conflicts of interest can be managed, reduced or eliminated.
_________________________________________________
DEAN FOR FACULTY DEVELOPMENT DATE
I have discussed the attached proposal with the PI. The budget numbers
described therein are appropriate and within College guidelines
___________________________________________________
CONTROLLER / ASSISTANT CONTROLLER DATE
The attached proposal is consistent with the overall objectives of the College
and all institutional concerns are resolved.
___________________________________________________
VP FOR FINANCE AND BUSINESS DATE
The attached proposal is consistent with the overall objectives of the College
and all institutional concerns are resolved.
___________________________________________________
PROVOST / VP DATE
PROJECT TITLE
TYPE: [ ] NEW [ ] RENEWAL [ ] REVISION
SOURCE: [ ] FEDERAL [ ] FOUNDATION [ ] CORPORATION [ ] STATE GOVT. [ ] OTHER
PURPOSE: [ ] RESEARCH [ ] INSTRUCTION [ ] FELLOWSHIP [ ] FINANCIAL AID
[ ] EQUIPMENT [ ] LEAVE SUPPORT [ ] OTHER/SPECIFY:
SUBCONTRACT ARRANGEMENTS:
as
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Page 2 of 4
The Dean for Faculty Development will assist faculty with this section.
COST SHARE INFORMATION (Cash/In-Kind/Waived Indirect Costs/Operating & Maintenance Costs)
Please describe the types of costs and the funding source and provide amounts.
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL PROJECT COST:
Request from Grantor $
College Contribution $
Third-Party (Other) $
TOTAL
$
INSTALLATION REQUIREMENTS
EXPLAIN:
Who at the College has reviewed these requirements?
SPACE OR RENOVATION NEEDS
Describe additional space or renovations that will be needed to carry out this project.
Who at the College has reviewed these needs?
EQUIPMENT / COMPUTERS / SOFTWARE REQUESTED
Item Cost College
Maintenance Arrangements
Share
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Who at the College has reviewed computer/technology purchases?
0.00
0.00
Page 3 of 4
RESEARCH CERTIFICATION
Human subjects? [ ] NO [ ] YES: Human Subjects Chair signature: Date
Animal research? [ ] NO [ ] YES: IACUC Approval signature: Date
Radioactive Materials? [ ] NO [ ] YES: Radiation Safety Officer signature Date
Signature required for “yes” answer only
CONFLICT OF INTEREST CERTIFICATION
(Required for all grant proposals that include government funds.)
I certify that I have provided an accurate and up-to-date statement of my significant financial interests and any other interests that
could be considered a conflict of interest. I agree to update this disclosure on an annual basis or as new reportable significant financial
interests or other conflicts of interest occur. If any conflicts of interest are identified, I agree to cooperate in a plan to manage, reduce,
or eliminate the conflict or forfeit the award.
Investigator 1:
Signature: Date:
Printed Name:
Investigator 2:
Signature: Date:
Printed Name:
Investigator 3:
Signature: Date:
Printed Name:
Investigator 4:
Signature: Date:
Printed Name:
Investigator 5:
Signature: Date:
Printed Name:
Investigator 6:
Signature: Date:
Printed Name:
(The Investigator Certification must be signed by every person included in the grant proposal who is an “investigator”. “Investigator”
is defined as the principal investigator/project director, co-principal investigators/co-principal project directors, and any other person
who is responsible for the design, conduct, or reporting of research or activities funded by an external grantor agency.)
Page 4 of 4
CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
(Required for all grant proposals that include government funds.)
I certify that:
(a) I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal
department or agency;
(b) I have not within a three-year period preceding the proposal been convicted of or had a civil judgment rendered against me 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; violation of Federal or State antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;
(c) I am not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with
commission of any of the offenses enumerated in paragraph (b) above; and
(d) I have not within the preceding three years had one or more public transactions (Federal, State, or local) terminated for cause or
default.
I will provide immediate written notice if I am debarred, suspended, or proposed for debarment by any government during the term of
this grant.
(If you are unable to certify to any of the statements in this certification, please attach an explanation to this proposal.)
Investigator 1:
Signature: Date:
Printed Name:
Investigator 2:
Signature: Date:
Printed Name:
Investigator 3:
Signature: Date:
Printed Name:
Investigator 4:
Signature: Date:
Printed Name:
Investigator 5:
Signature: Date:
Printed Name:
Investigator 6:
Signature: Date:
Printed Name:
The Proposal Transmittal Form must accompany all grant proposals that will be submitted for outside funding. The Principal Investigator/Project
Director is responsible for obtaining the appropriate signatures. All proposals from faculty must be received by the Dean for Faculty Development
before being submitted to the Provost for approval and signature. Failure to obtain the signature of the Provost or Vice President on the routing
form for any grant proposal may result in the Institution's refusal to accept the grant if awarded. The form will not be sent with the proposal, but
will be kept on file in the office of the Provost or Vice President.
Revised 5/11/10
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Completed 16 November 2019

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