ࡱ>  bjbj eeU6 ff$P*<( !lH"8k;m;m;m;m;m;m;$j>Az;" @ "";ffB<((("Rf8k;("k;((ri1Ti2& +"1W;X<0<1A$Ai2i2FA2""(""""";;&2"""<""""A""""""""" ,:  I. INVESTIGATOR/CONTRACTOR DATA PI: FORMTEXT       Name FORMTEXT       FORMTEXT       FORMTEXT      Phone NumberDepartmentEmail Address II. PROJECT INFORMATION Proposal Type  FORMDROPDOWN Project Activity  FORMDROPDOWN Title  FORMTEXT      Sponsor Name  FORMTEXT      Sponsor Type  FORMDROPDOWN Proposal Due Date:  FORMTEXT       What is the planned project start date?  FORMTEXT      How many years will the project run if funded?  FORMTEXT       III. PROJECT ABSTRACT (1,500 character limit) (please include number of students affected by this proposal, if any)  FORMTEXT       IV. REGULATORY & INSTITUTIONAL ISSUES Does the proposal involve or require any of the following?  Yes No Yes No* Human Research Participants  FORMCHECKBOX   FORMCHECKBOX Foreign Travel / Foreign Collaborators  FORMCHECKBOX   FORMCHECKBOX * Laboratory Animal Care  FORMCHECKBOX   FORMCHECKBOX Plan to host project-related events at 91pron?   FORMCHECKBOX   FORMCHECKBOX * Any Biosafety Level (BSL) 1 or higher material, or work involving recombinant DNA  FORMCHECKBOX   FORMCHECKBOX New biweekly personnel position(s) must be approved (new full-time position / hire(s) with benefits needed?) Grant funded positions terminate when the grant award period ends  FORMCHECKBOX   FORMCHECKBOX * If yes to any above, have you submitted for IRB, IACUC, or IBC committee review?  FORMCHECKBOX   FORMCHECKBOX Building alterations (renovations, new construction or more space required?)  FORMCHECKBOX   FORMCHECKBOX Patentable / proprietary information? If so, please mark such info as confidential.  FORMCHECKBOX   FORMCHECKBOX Are you requesting 91pron provide a reduction in some/all tuition costs for students in the proposed program? If yes, complete Section VI: Group-Level Scholarship  FORMCHECKBOX   FORMCHECKBOX   Are you or any other personnel requesting course offload/release time? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, complete table. Attach more info if needed. The 91pron/AFT Collective Bargaining Agreement specifies that, No academic year faculty shall receive as extra compensation, exclusive of summer session and department chairperson stipend, any more than 20 percent of his/her academic year salary in any single academic year and normally may not carry more than four (4) formula hours outside of load in any semester. Consistent with Appendix D of the Collective Bargaining Agreement, academic year faculty may not carry more than 24 load hours of overload over the two years of the contract, except under extraordinary circumstances and with the prior approval of the dean and VPAA. This limit is exclusive of summer session and the department chair formula hours and applies to all full-time faculty at the college. Name of Faculty# of load hoursDuring which semester(s)?Supported by grant  FORMTEXT       FORMTEXT       FORMTEXT      In grant budget  FORMCHECKBOX  not In grant budget  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      In grant budget  FORMCHECKBOX  not In grant budget  FORMCHECKBOX Grant funded positions terminate when the grant award period ends. Call ORGA (x8228) if you have questions.V. BUDGET INFORMATION: PLEASE COMPLETE THE ATTACHED BUDGET PAGE. The proposed F&A/Indirect cost rate above is:  FORMTEXT     % of  FORMDROPDOWN . (if voluntarily reducing 91prons F&A rate below Is this the maximum F&A rate allowed by the sponsor? Yes  FORMCHECKBOX  No  FORMCHECKBOX  standard/sponsor rate, attach justification.) If no F&A, operating cost chargebacks (room rental & other college fees) represent  FORMTEXT     % of the total project budget. VI. Group-Level Scholarship (Reduced tuition rate) This section must be completed if you are requesting a reduction in the tuition rate for students participating in the proposed project. (Questions regarding this section should be directed to Dante Del Giudice,  HYPERLINK "mailto:ddelgiudice@ric.edu" ddelgiudice@ric.edu or x8428) Rationale for Group-Level Scholarship: How does the proposed course/program contribute to 91prons mission? Please identify tangible and measurable benefits and any evidence to substantiate your rationale. (300 Character limit. Attach additional page if needed.)  FORMTEXT       Group-Level Scholarship (G-LS) Proposal Current undergraduate or graduate in-state tuition for 1 Cr Hr$ FORMTEXT      Proposed Group-Level Scholarship (reduction)$ FORMTEXT      G-LS Rate (1 Cr Hr tuition minus G-LS)$ FORMTEXT       Programming Budget Estimate $  FORMTEXT       G-LS Rate $  FORMTEXT       Total credit hours for proposed course/program $  FORMTEXT       Projected enrollment $  FORMTEXT       Total tuition revenue (a. X b. X c; All tuition/fee revenue must be collected by Bursar or PSCE) VII. APPROVALS AND CERTIFICATIONS The undersigned certify that neither the PI nor anyone proposed to work on this project are, to the best of their knowledge, excluded from participation in Federally-funded activities as a result of government-wide suspension or debarment. Conflict of Interest: I certify by my signature below that I, and every individual meeting the definition of Investigator (see next page), have completed the Conflict of Interest Investigator Financial Disclosure Statement. The CITI certificate of completion for Financial Conflict of Interest (COI) online training is attached here or on file with ORGA. Responsible Conduct of Research: I certify by my signature below that I and all Senior Personnel (see attached budget page) have completed the Responsible Conduct of Research (RCR) online training through CITI. The CITI certificate of completion is attached here or on file with ORGA. Any students funded through this research will complete the CITI training. Their names will be provided to ORGA for verification of completion. Principal Investigator: By signing below, I certify (1) that the information submitted within the application is true, complete and accurate to the best of the my knowledge; (2) that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties; and (3) that I agree to accept responsibility for the scientific conduct of the project and all areas of compliance. I will provide required progress reports if a grant is awarded as a result of this application. I agree to abide by college and sponsor policies and procedures in the performance of the grant award should my application be funded. VIII. SIGNATURES Collect signatures in number order below. ORGA ( Roberts 408) will secure signatures from #4 to completion. _________________________________________________ ____________________________________________________ 1. PI Signature Date 2. Department Chair/Director Date (certifies that all information is true and correct/ (supports application/approves course offloads and proposed assumes grant management and oversight responsibility) effort/special departmental requests) _________________________________________________ ______________________________________________________ 1a. Co-PI Signature(s) Date 2a. Department Chair(s)/Director(s) for Co-PI(s) Date (certifies that all the information is true and correct) (supports application/approves course offloads and proposed effort/special departmental requests) _________________________________________________ ____________________________________________________ 3. School/College Dean Date 3a. School/College Dean(s) for Co-PI(s) Date (supports application/ reviews sponsor budget and cost-share (supports application/reviews sponsor budget and cost-share budget/ budget/approves course offload requests/approves special approves course offload requests/approves special departmental departmental requests) requests) __________________________________________ __________________________________________ 4. Director of Research & Grants Date 5. Budget Director Date (reviews form for accuracy/insures approvals and certifications/ (reviews new and current FTE position requests/reviews requested reviews budget, including cost-share, for accuracy/reviews compliance cost-share budget/reviews personnel cost estimate) issues/certifies to conflict of interest) ____________________________________________________ _______________________________________________________ 6. Controller Date 7. Vice President (other than VPAA) as appropriate (reviews F&A rate and related support/cost-share commitment) (supports application and alignment with academic mission/ cost-share budget/ reviews personnel cost estimates) reviews cost share/reviews course offloads and proposed effort) _________________________________________________ ____________________________________________________ 8. Vice President for Academic Affairs Date 9. President Date (supports application and alignment with academic mission/ reviews cost-share/reviews course offloads and proposed effort)  91pron IX. Conflict of Interest Investigator Financial Disclosure Statement I certify that I have read the Financial Disclosure Policy on the 91pron Office of Research and Grants Administration (ORGA) website  HYPERLINK "http://www.ric.edu/orga/policies_coi.php" http://www.ric.edu/orga/policies_coi.php, which is effective for all external proposals submitted through the College. I have completed The Financial Conflict of Interest online training through CITI. A copy of the CITI completion certificate is attached or on file with ORGA.  FORMCHECKBOX  I certify to the best of my knowledge that neither I, nor my spouse, partner, or dependents hold any significant financial interests that would reasonably be affected by the research, educational or creative activities proposed for, or currently supported by external funding, or in any entities whose financial interests would reasonably be affected by such activities.  FORMCHECKBOX  I have relationships, affiliations, activities, or interests (financial or otherwise) which constitute potential conflicts under federal conflict of interest regulations. I have submitted a completed Financial Disclosure Form  HYPERLINK "http://www.ric.edu/orga/policies_coi.php" http://www.ric.edu/orga/policies_coi.php to the colleges Research Integrity Officer (RIO Director, ORGA) for any potential conflicts that may be Significant Financial Interests. If any situations arise of which I am aware, that are contradictory in any way to the above statement, I will immediately notify the RIO and make full disclosure of any conflict, real or potential. 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Regulations apply to collaborators, consultants, post-doctoral fellows, graduate students and others, as well as any individual meeting definition of investigator at awardee and subrecipient organizations. Each individual meeting this definition of investigator must complete this Financial Disclosure Statement. Exclusions: The 2011 revised regulation modifies the types of interests that are specifically excluded from the Significant Financial Interest definition. Exclusions are: salary, royalties, or other remuneration paid by the Institution to the Investigator if the Investigator is currently employed or otherwise appointed by the Institution; intellectual property rights assigned to the Institution and agreements to share in royalties related to such rights; any ownership interests in the Institution held by the Investigator, if the Institution is a commercial or for-profit organization; income from investment vehicles, such as mutual funds and retirement accounts, as long as the Investigator does not directly control the investment decisions made in these vehicles; income from seminars, lectures, or teaching engagements sponsored by a federal, state, or local government agency, an Institution of higher education as defined in 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an institution of higher education; income from service on advisory committees or review panels for a federal, state, or local government agency, or an Institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an institution of higher education.     Notice: No proposals will be institutionally authorized for submission without this forms completion. This form must be completed for all grants and contracts including continuations and extensions. It must be completed annually, including multi-year contracts and awards. ______________________________________________________________________________________________________________________________ Page  PAGE 2 of  NUMPAGES 4 PROPOSAL SUMMARY / APPROVAL FORM  HYPERLINK "http://www.ric.edu/grants" http://www.ric.edu/grants Form revision: 09/2016 Submit to ORGA at least 2 weeks prior to proposal deadline. Form required to submit proposal and again before each year of a continuation award. 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