DEPARTMENT OF HEALTH AND HUMAN SERVICESPUBLIC HEALTH SERVICENATIONAL INSTITUTES OF HEALTH
PROPOSAL SUMMARY AND DATA RECORDPROPOSAL SUMMARY AND DATA RECORD
RFP NUMBER/CONTRACT NUMBERPROJECT TITLE (Title of RFP or Contract Proposal)LEGAL NAME AND ADDRESS OF OFFERORPLACE OF PERFORMANCE (Full address including ZIP)TYPE OF CONTRACT PROPOSED
o
COST-REIMBURSEMENT
o
FIXED PRICE
o
COST-PLUS-FIXED-FEE
o
OTHERESTIMATED TIME REQUIRED TO COMPLETE PROJECTPROPOSED STARTING DATEESTIMATED DIRECT COSTS IN PROPOSED YEAR (From budget)DOES THIS PROPOSAL INCLUDE A SUBCONTRACT
o
YES
o
NO (If yes, please furnish name and location of organization, description of services, basis for selection, responsibleperson employed by subcontractor and cost information.)NAME AND TITLE OF PRINCIPAL INVESTIGATORSOCIAL SECURITY NO.EST. HOURS WEEKLYAREA CODE/TEL. NO.NAME AND TITLE OF CO-INVESTIGATORS (Use attachment if necessary)SOCIAL SECURITY NO.EST. HOURS WEEKLYAREA CODE/TEL. NO.NAME AND TITLE OF INDIVIDUAL(S) AUTHORIZED TO NEGOTIATE CONTRACTSAREA CODE/TELEPHONE NUMBERNAME AND TITLE OF INDIVIDUAL(S) AUTHORIZED TO EXECUTE CONTRACTSAREA CODE/TELEPHONE NUMBERDOES THIS PROPOSAL INVOLVE EXPERIMENTS WITH HUMAN SUBJECTS?
o
YES
o
NOInstitution's General Assurance re Human SubjectsDATE APPROVED
o
PENDINGInstitution's Review Board's approval of this proposalDATE APPROVED
o
PENDING An example of the informed consent for this study is enclosed
o
YES
o
NO A Clinical Protocol is enclosed
o
YES
o
NOOFFEROR'S ACKNOWLEDGEMENT OF AMENDMENTS TO THE RFP (Use attachment if necessary)ERRATA NUMBERDATEERRATA NUMBERDATENAME, ADDRESS, AND PHONE NUMBER OF COGNIZANT GOVERNMENT AUDIT AGENCYNUMBER OF EMPLOYEES CURRENTLY EMPLOYEDDOLLAR VOLUME OF BUSINESS PER ANNUMTHIS OFFER EXPIRES DAYS FROM THE DATEOF THIS OFFER. (120 days if not specified)FOR THE INSTITUTIONSIGNATURE OF PRINCIPAL INVESTIGATORSIGNATURE OF BUSINESS REPRESENTATIVETYPED NAME AND TITLETYPED NAME AND TITLEEMPLOYER IDENTIFICATION NUMBERDATE OF OFFERNIH 2043 (Rev. 6/82)
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National Institutes of Health: nih2043
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| Rating: | (2 Ratings) |
| Upload Date: | 01/20/2008 |
| Copyright: | Attribution Non-commercial |
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