PI Name
Project Title
Page 1
OFFICE USE ONLY
Michigan Tech Proposal #
Date submitted
I. PROJECT INFORMATION
Title
Project Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)
Are you responding to a Request for Proposal (RFP) or solicitation? No Yes (If yes, attach copy and/or list website below)
Website address
Does the sponsor or solicitation limit the number of proposals submitted per institution?
No Yes (See Michigan Technological University guidelines)
Project Director/PI & Co-PI(s)
Title
Phone
Email
Department
PI
Co-PI
Co-PI
Co-PI
Co-PI
Institute/Center for project (if applicable)
NOTE: Only one Institute or Center is allowed per project.
SPONSOR INFORMATION
Name
Mailing Address
Prime Source of Funds - If pass-through funding is from a Federal or
State agency, or any other third party, enter the source entity for the funding.
Contact
Phone
Email
Date
(mm/dd/yyyy)
Time
Not Applicable Sponsor Deadline
Electronic submission:
Hard copy submission:
Received by: (mm/dd/yyyy)
Postmarked by: (mm/dd/yyyy)
Time
Time
Index number for expedited mailings:
COMMENTS:
Pre-Proposal - request to sponsor for preliminary review prior to a formal or new proposal submission
New - original submission of a full proposal
Revision request
for modifications to a previous submission (e.g., scope, budget, etc.) to proposal #
Supplement request for additional funds during an approved project period to proposal #
Continuation/Renewal request for additional funds beyond the approved project period for proposal #
Sponsored Project Proposal Transmittal Sheet
Submit completed form including scope of work, budget and other submission information by email to: spo-l@mtu.edu
Proposal Type - check one box only
Reset Form
Updated: July 10, 2020
PI Name
Project Title
Page 2
II. PROJECT BUDGET
Is cost share required by the sponsor, RFP, and/or
solicitation? No Yes
If yes, specify the percentage or dollar amount and complete the
Cost Share Authorization form.
Are F&A costs limited by the sponsor, RFP, and/or
solicitation? No Yes
If yes, to what amount is the rate limited?
List the anticipated Subaward recipients:
Note: a Subrecipient Commitment Form must be completed for each
recipient prior to proposal submission.
Are graduate student tuition charges explicitly prohibited or
limited by the sponsor, RFP, and/or solicitation?
No Yes
If yes, to what amount are the charges limited?
NOTE: If multiple indexes are required, include a budget for each
Applicable Facilities and Administrative Rate (F&A) for Project
Research & Development
Non-DoD &
Non-Industry contracts
Research & Development
DoD & Industry
contracts
Instruction Other Sponsored
Activities
Michigan Tech
On-Campu
s
Michigan Tech Off-Campus*
MTRI On-Campus
MTRI Off-Campus*
Student fellowships or scholarships
* Off-Campus definition More than 50% of expenditures, excluding subawards, incurred for activities conducted on property not
owned or leased by Michigan Tech. If Off-Campus' is selected above, specify performance site:
54.6%
72.3 54.0%
35.8%
26%26%
44.4%
26%
52.9%
26%
58.0%
84.2%
N/A
Estimated Sponsor Request
Estimated Cost Share
Estimated Total Project Value
III. PROJECT REQUIREMENTS
All resources necessary to conduct the proposed work, including adequate and suitable space, equipment and information technology
capabilities are currently available.
No
Yes
$ 0
PI Name
Project Title
Page 3
IV. COMPLIANCE
Research Integrity
IRB Human Subjects
IACUC Animal Subjects
Laboratory
Field Study
IBC Biological
Recombinant/Synthetic Nucleic Acids Research
Other (e.g., infectious agents, cells, tissues, organs, exotic/invasive species, biological toxins)
Foreign National Restrictions
No Yes The RFQ or RFP includes a restriction or potential restriction on the involvement of a foreign national
on this
project.
Radioactive Materials Radiation Safety Officer (487-2131)
No
Yes Does this project involve the use of radioactive materials? If yes, approval is required by Radiation Safety Officer
V. MISCELLANEOUS
Does this project involve
outreach activities with any of the following educational groups?
K-12
Community College(s)
- A foreign person is anyone who is not either A) a U.S. citizen, B) a Lawful Permanent Residents (aka Green Card holder).
- A foreign entity is a foreign corporation, business association, partnership or any other entity or group that is not incorporated to
do business in the United States.
If yes, please indicate A) the foreign entity(s)
or person(s) and B) the country(ies) involved:
Export Controls Facility Security Officer (487-2654)
Does the project include travel to a foreign country or transfer/delivery of any materials, items, or information to a foreign person
or entity?
No Yes
When answering this question, please note the following:
Data - collection/use/analysis
Biospecimen - collection/use/analysis
PRIOR to any award, all proposed projects involving the use of animals, human subjects, or biological materials require review and approval by the
appropriate regulatory committee (IACUC/IRB/IBC). Contact the RI office at 487-2902 or researchintegrity@mtu.edu with questions.
PI Name
Project Title
Page 4
Principal Investigator
Certifications
Principal Investigator (PI) must read, sign, and obtain necessary authorizations for this form.
(NOTE: Each Co-PI must read, sign, and obtain necessary authorizations on a separate Co-PI Certification Form.)
In compliance with Michigan Technological Universitys policies, procedures and practices regar
ding the conduct of
externally funded activities, I certify the following:
1. I certify and attest that the information submitted within the accompanying application is original, true, complete, and accurate.
I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative
penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if
a grant is awarded as a result of this application.
2. I certify that I have read and understand my responsibilities toward this sponsored project and, if funded, I will exercise
the responsibilities as outlined in Michigan Techs Sponsored Project Responsibilities.
3. I certify that I am neither presently debarred or suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participating in current transactions by any federal department or agency, and I am not delinquent on any federal debt.
4. I certify that I have read, understand, and will comply with the Universitys Policy on Misconduct in Research, Scholarly
and Creative Endeavors.
5. I certify that I have read and understand Michigan Techs Conflict of Interest Policy (COIP) and Michigan Techs Conflict of
Interest Procedures and that I will comply with the COIP and all conditions or restrictions imposed by Michigan Tech to manage
conflicts of interest or I will forfeit the award. I further certify that I will continue to comply with the COIP throughout the life of
this project and will complete a new Conflict of Interest Disclosure form if circumstances arise that would warrant a positive
disclosure on sponsored projects.
6. If this application for funding is directly or indirectly from Public Health Service (PHS) agencies, I certify that I have read and
understand Michigan Tech’s Conflict of Interest Policy and Michigan Tech’s Conflict of Interest Procedures (PHS Specific), and
that I will comply with the Policy and Procedures throughout the life of this project and will continue to complete the annual
Conflict of Interest Disclosure Form for PHS projects or make modifications if circumstances arise that would warrant further
disclosure.
7. I certify that if I receive federal funding via any mechanism, I
agree to comply with all public/open access terms of the sponsor.
8. I certify that I am responsible for any short-fall in graduate student tuition and fees when budgeting in candidacy mode.
Principal Investigator (PI)
Conflict of Interest
No Yes
Principal Investigator Name (Please Print or Type) Prin
cipal Investigator Signature (Required) If yes, indicate date
disclosure filed:
Date
Date
Authorizing Signatures
Department Chair/Director Name (Please Print or Type) Department Chair/Director Signature Date
OR
College/School Dean Signa
ture or Executive (if applicable) Date
Center/Institute
Director Name (Please Print or Type)
Center/Institute
Director Signature (if applicable) Date
College/School Dean Name or Executive (Please Print or Type)
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PI Name
Project Title
Page 5
Co-Principal Investigator
Certifications
Each Co-PI must read, sign, and obtain necessary authorizations on a separate form (if applicable).
In compliance with Michigan Technological Universitys policies, procedures and practices regarding the conduct of
externally funded activities, I certify the following:
1. I certify and attest that the information submitted within the accompanying application is original, true, complete, and accurate.
I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative
penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if
a grant is awarded as a result of this application.
2. I certify that I have read and understand my responsibilities toward this sponsored project and, if funded, I will exercise
the responsibilities as outlined in Michigan Techs Sponsored Project Responsibilities.
3. I certify that I am neither presently debarred or suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participating in current transactions by any federal department or agency, and I am not delinquent on any federal debt.
4. I certify that I have read, understand, and will comply with the Universitys Policy on Misconduct in Research, Scholarly
and Creative Endeavors.
5. I certify that I have read and understand Michigan Techs Conflict of Interest Policy (COIP) and Michigan Techs Conflict of
Interest Procedures and that I will comply with the COIP and all conditions or restrictions imposed by Michigan Tech to manage
conflicts of interest or I will forfeit the award. I further certify that I will continue to comply with the COIP throughout the life of
this project and will complete a new Conflict of Interest Disclosure form if circumstances arise that would warrant a positive
disclosure on sponsored projects.
6. If this application for funding is directly or indirectly from Public Health Service (PHS) agencies, I certify that I have read and
understand Michigan Tech’s Conflict of Interest Policy and Michigan Tech’s Conflict of Interest Procedures (PHS Specific), and
that I will comply with the Policy and Procedures throughout the life of this project and will continue to complete the annual
Conflict of Interest Disclosure Form for PHS projects or make modifications if circumstances arise that would warrant further
disclosure.
7. I certify that, if I receive federal funding via any mechanism, I agree to comply with all public/open access terms of the sponsor.
Co-Principal Investigator (Co-PI)
Conflict of Interest
No Yes
Co-Pri
ncipal Investiga
t
o
r
N
a
m
e
(Pl
e
ase
Pri
n
t
o
r
T
ype) Co-Principal In
vestigator Signature (Required)
If yes, indicate date
disclosure filed:
Date Date
Authorizing Signatures
Department Chair/Director Name (Please Print or Type) Department Chair/Director Signature Date
OR
College/School Dean Signa
ture or Executive (if applicable) Date
College/School Dean Name or Executive (Please Print or
Type)
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click to sign
signature
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PI Name
Project Title
Page 6
Co-Principal Investigator
Certifications
Each Co-PI must read, sign, and obtain necessary authorizations on a separate form (if applicable).
In compliance with Michigan Technological Universitys policies, procedures and practices regarding the conduct of
externally funded activities, I certify the following:
1. I certify and attest that the information submitted within the accompanying application is original, true, complete, and accurate.
I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative
penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if
a grant is awarded as a result of this application.
2. I certify that I have read and understand my responsibilities toward this sponsored project and, if funded, I will exercise
the responsibilities as outlined in Michigan Techs Sponsored Project Responsibilities.
3. I certify that I am neither presently debarred or suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participating in current transactions by any federal department or agency, and I am not delinquent on any federal debt.
4. I certify that I have read, understand, and will comply with the Universitys Policy on Misconduct in Research, Scholarly
and Creative Endeavors.
5. I certify that I have read and understand Michigan Techs Conflict of Interest Policy (COIP) and Michigan Techs Conflict of
Interest Procedures and that I will comply with the COIP and all conditions or restrictions imposed by Michigan Tech to manage
conflicts of interest or I will forfeit the award. I further certify that I will continue to comply with the COIP throughout the life of
this project and will complete a new Conflict of Interest Disclosure form if circumstances arise that would warrant a positive
disclosure on sponsored projects.
6. If this application for funding is directly or indirectly from Public Health Service (PHS) agencies, I certify that I have read and
understand Michigan Tech’s Conflict of Interest Policy and Michigan Tech’s Conflict of Interest Procedures (PHS Specific), and
that I will comply with the Policy and Procedures throughout the life of this project and will continue to complete the annual
Conflict of Interest Disclosure Form for PHS projects or make modifications if circumstances arise that would warrant further
disclosure.
7. I certify that, if I receive federal funding via any mechanism, I agree to comply with all public/open access terms of the sponsor.
Co-Principal Investigator (Co-PI)
Conflict of Interest
No Yes
Co-Principal Investigator Name (Please Print or Type) Co-Principal Investigator Signature (Required) If yes, indicate date
disclosure filed:
Date Date
Authorizing Signatures
Department Chair/Director Name (Please Print or Type) Department Chair/Director Signature Date
OR
College/School Dean Signature or Executive (if applicable) Date
College/School Dean Name or Executive (Please Print or
Type)
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signature
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PI Name
Project Title
Page 7
Co-Principal Investigator
Certifications
Each Co-PI must read, sign, and obtain necessary authorizations on a separate form (if applicable).
In compliance with Michigan Technological Universitys policies, procedures and practices regarding the conduct of
externally funded activities, I certify the following:
1. I certify and attest that the information submitted within the accompanying application is original, true, complete, and accurate.
I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative
penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if
a grant is awarded as a result of this application.
2. I certify that I have read and understand my responsibilities toward this sponsored project and, if funded, I will exercise
the responsibilities as outlined in Michigan Techs Sponsored Project Responsibilities.
3. I certify that I am neither presently debarred or suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participating in current transactions by any federal department or agency, and I am not delinquent on any federal debt.
4. I certify that I have read, understand, and will comply with the Universitys Policy on Misconduct in Research, Scholarly
and Creative Endeavors.
5. I certify that I have read and understand Michigan Techs Conflict of Interest Policy (COIP) and Michigan Techs Conflict of
Interest Procedures and that I will comply with the COIP and all conditions or restrictions imposed by Michigan Tech to manage
conflicts of interest or I will forfeit the award. I further certify that I will continue to comply with the COIP throughout the life of
this project and will complete a new Conflict of Interest Disclosure form if circumstances arise that would warrant a positive
disclosure on sponsored projects.
6. If this application for funding is directly or indirectly from Public Health Service (PHS) agencies, I certify that I have read and
understand Michigan Tech’s Conflict of Interest Policy and Michigan Tech’s Conflict of Interest Procedures (PHS Specific), and
that I will comply with the Policy and Procedures throughout the life of this project and will continue to complete the annual
Conflict of Interest Disclosure Form for PHS projects or make modifications if circumstances arise that would warrant further
disclosure.
7. I certify that, if I receive federal funding via any mechanism, I agree to comply with all public/open access terms of the sponsor.
Co-Principal Investigator (Co-PI)
Conflict of Interest
No Yes
Co-Principal Investigator Name (Please Print or Type) Co-Principal Investigator Signature (Required) If yes, indicate date
disclosure filed:
Date Date
Authorizing Signatures
Department Chair/Director Name (Please Print or Type) Department Chair/Director Signature Date
OR
College/School Dean Signature or Executive (if applicable) Date
College/School Dean Name or Executive (Please Print or Type)
Electronic signatures are available on this document. Click on RED ARROW of the signature field and follow the prompts. Save the file, and email to the next signator.
click to sign
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PI Name
Project Title
Page 8
Co-Principal Investigator
Certifications
Each Co-PI must read, sign, and obtain necessary authorizations on a separate form (if applicable).
In compliance with Michigan Technological Universitys policies, procedures and practices regarding the conduct of
externally funded activities, I certify the following:
1. I certify and attest that the information submitted within the accompanying application is original, true, complete, and accurate.
I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative
penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if
a grant is awarded as a result of this application.
2. I certify that I have read and understand my responsibilities toward this sponsored project and, if funded, I will exercise
the responsibilities as outlined in Michigan Techs Sponsored Project Respsonsibilities.
3. I certify that I am neither presently debarred or suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participating in current transactions by any federal department or agency, and I am not delinquent on any federal debt.
4. I certify that I have read, understand, and will comply with the Universitys Policy on Misconduct in Research, Scholarly
and Creative Endeavors.
5. I certify that I have read and understand Michigan Techs Conflict of Interest Policy (COIP) and Michigan Techs Conflict of
Interest Procedures and that I will comply with the COIP and all conditions or restrictions imposed by Michigan Tech to manage
conflicts of interest or I will forfeit the award. I further certify that I will continue to comply with the COIP throughout the life of
this project and will complete a new Conflict of Interest Disclosure form if circumstances arise that would warrant a positive
disclosure on sponsored projects.
6. If this application for funding is directly or indirectly from Public Health Service (PHS) agencies, I certify that I have read and
understand Michigan Tech’s Conflict of Interest Policy and Michigan Tech’s Conflict of Interest Procedures (PHS Specific), and
that I will comply with the Policy and Procedures throughout the life of this project and will continue to complete the annual
Conflict of Interest Disclosure Form for PHS projects or make modifications if circumstances arise that would warrant further
disclosure.
7. I certify that, if I receive federal funding via any mechanism, I agree to comply with all public/open access terms of the sponsor.
Co-Principal Investigator (Co-PI)
Conflict of Interest
No Yes
Co-Principal Investigator Name (Please Print or Type) Co-Principal Investigator Signature (Required) If yes, indicate date
disclosure filed:
Date Date
Authorizing Signatures
Department Chair/Director Name (Please Print or Type) Department Chair/Director Signature Date
OR
College/School Dean Signature or Executive (if applicable) Date
College/School Dean Name or Executive (Please Print or Type)
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PI Name
Project Title
Page 9
OFFICE USE ONLY
Sponsored Programs
Project Type (majority of project)
Instruction
Other Sponsored Activities
Other - Public Service
Other - Student Fellowship
Other - Student Scholarship
Research and Development
Research and Development - Enterprise
Research and Development - Student Design
Research and Development - Testing
Funding Source Type
Federal
Federal Prime: _
Federal pass through
Federal pass through - Industry
Foreign
Foreign Industry
Industry
Internal
Other
Other Association/Society
Other Foundation
State of MI
State Prime: _____________________________
State of MI pass through
State of MI pass through - Industry
Virtuals
Program Name
CFDA #
Analyst:
Approval for budget, sponsor, and Michigan Tech policies conformity Date University approval for transmission to the above-named sponsor Date
Disclosure Restrictions?
Limited Sharing
DO NOT SHARE
DoD Appropriations Act (6.1 Funds)
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