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PeopleSoft 8.4 Grants Reports
PeopleSoft 8.4 Grants Reports
SKU Fr84GMT-R 0302
PeopleBooks Contributors: Teams from PeopleSoft Product Documentation and
Development.
Copyright © 1992-2002 PeopleSoft, Inc. All rights reserved.
Printed in the United States.
All material contained in this documentation is proprietary and confidential to PeopleSoft,
Inc. ("PeopleSoft"), protected by copyright laws and subject to the nondisclosure provisions
of the applicable PeopleSoft agreement. No part of this documentation may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, including, but not
limited to, electronic, graphic, mechanical, photocopying, recording, or otherwise without the
prior written permission of PeopleSoft.
This documentation is subject to change without notice, and PeopleSoft does not warrant that
the material contained in this documentation is free of errors. Any errors found in this
document should be reported to PeopleSoft in writing.
The copyrighted software that accompanies this document is licensed for use only in strict
accordance with the applicable license agreement which should be read carefully as it
governs the terms of use of the software and this document, including the disclosure thereof.
PeopleSoft, the PeopleSoft logo, PeopleTools, PS/nVision, PeopleCode, PeopleBooks,
PeopleTalk, and Vantive are registered trademarks, and "People power the internet." and Pure
Internet Architecture are trademarks of PeopleSoft, Inc. All other company and product
names may be trademarks of their respective owners. The information contained herein is
subject to change without notice.
P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L C O N T E N T S i i i
C o n t e n t s
About This PeopleBook
Related Documentation .......................................................................................................v
Documentation on CD-ROM........................................................................................v
Hardcopy Documentation.............................................................................................v
Comments and Suggestions ...............................................................................................vi
Chapter 1
PeopleSoft Grants Reports
Reporting for Grants ....................................................................................................... 1-1
Federal Forms – PHS 398......................................................................................... 1-1
Federal Forms – PHS 2590....................................................................................... 1-2
Administrative Reports............................................................................................. 1-3
Billing Forms............................................................................................................ 1-4
Report Samples
P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L P R E F A C E v
About This PeopleBook
This book describes information about PeopleSoft 8.4 Grants Reports. You can order the
online version by requesting SKU FSCM84PBR0, or the hardcopy version by requesting SKU
Fr84GMT-R 0302.
Related Documentation
To add to your knowledge of PeopleSoft applications and tools, you may want to refer to the
documentation of other PeopleSoft applications. You can access additional documentation for
this and previous releases from PeopleSoft Customer Connection
(http://www.peoplesoft.com/corp/en/public_index.asp).
Through the Documentation section of Customer Connection, you can download files to add
to your PeopleBooks library. You'll find a variety of useful and timely materials, including
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Important! Before upgrading, it is imperative that you check PeopleSoft Customer
Connection for updates to the upgrade instructions. We continually post updates as we refine
the upgrade process.
Documentation on CD-ROM
Complete documentation for this release is provided on the CD-ROM PeopleSoft 8.4
Financials and Supply Chain Management PeopleBooks, SKU FSCM84PBR0.
Hardcopy Documentation
To order printed, bound volumes of the complete PeopleSoft documentation delivered on your
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We make printed documentation for each major release available shortly after the software is
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P E O P L E S O F T 8 . 4 G R A N T S R E P O R T S
P R E F A C E v i P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L
Internet From the main PeopleSoft internet site, go to the
Documentation section of Customer Connection. You can
find order information under the Ordering PeopleBooks
topic. Use a Customer Connection ID, credit card, or
purchase order to place your order.
PeopleSoft internet site: http://www.peoplesoft.com.
Telephone Contact Consolidated Publishing Incorporated (CPI) at
800 888 3559.
Email Email CPI at [email protected].
Comments and Suggestions
Your comments are important to us. We encourage you to tell us what you like, or what you
would like changed, about our documentation, PeopleBooks, and other PeopleSoft reference
and training materials. Please send your suggestions to:
PeopleSoft Product Documentation Manager
PeopleSoft, Inc.
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Or send comments by email to the authors of PeopleSoft documentation at:
While we cannot guarantee to answer every email message, we will pay careful attention to
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you.
P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L P E O P L E S O F T G R A N T S R E P O R T S 1 - 1
C H A P T E R 1
PeopleSoft Grants Reports
This chapter lists all the reports provided with PeopleSoft Grants and includes general
information about specific reports.
Note. For samples of these reports, see the Portable Document Format (PDF) fields that are
published on CD-ROM with your documentation.
Reporting for Grants
PeopleSoft Grants enables you to compile and run a variety of delivered reports, from
federally required financials reports to system reports. The following forms and reports are
delivered with PeopleSoft Grants.
See Also
http://www.nih.gov/grants/forms.htm
PeopleSoft Application Fundamentals for FIN, ESA, and SCM PeopleBook, Understanding
PeopleSoft Financial Global Reports
Federal Forms – PHS 398
Report ID
Report Name
Description Navigation Run Control Page
PHS 398 - Form Page 1 Face Page. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Form Page 2 Description,
Performance Sites,
Key Personnel.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Form Page 3 Research Grant Table
of Contents.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Form Page 4 Detailed Budget for
Initial Budget Period.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Form Page 5 Budget for Entire
Period: Direct Costs.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
P E O P L E S O F T 8 . 4 F I N A N C I A L S A N D S U P P L Y C H A I N M A N A G E M E N T P E O P L E B O O K S
1 - 2 P E O P L E S O F T G R A N T S R E P O R T S P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L
Report ID
Report Name
Description Navigation Run Control Page
PHS 398 - Modular
Budget Format Page
Modular Budget. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 -
Biographical Sketch
Format Page
Biographical Sketch. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Resources
Format Page
Resources. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Checklist
Form Page
Checklist. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Personal
Data Form Page
Personal Data on
PI/PD.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 -
Continuation Page
Continuation. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 -
Targeted/Planned
Enrollment Format
Page
Targeted/Planned
Enrollment.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Enrollment
Report Format Page
Enrollment Report. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Other
Support Format Page
Other Support. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 398 - Personnel
Report Format Page
Personnel Report. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
Federal Forms – PHS 2590
Report ID
Report Name
Description Navigation Run Control Page
PHS 2590 - Form Page
1
Face Page. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 - Form Page
2
Detailed Budget for
Next Budget Period.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 - Form Page
3
Budget Justification. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 -
Biographical Sketch
Biographical Sketch. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 - Form Page
5
Progress Report
Summary.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 - Form Page
6
Checklist. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
P E O P L E S O F T 8 . 4 F I N A N C I A L S A N D S U P P L Y C H A I N M A N A G E M E N T P E O P L E B O O K S
P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L P E O P L E S O F T G R A N T S R E P O R T S 1 - 3
Report ID
Report Name
Description Navigation Run Control Page
PHS 2590 - Form Page
7
Personnel. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 -
Continuation Page
Continuation Page. Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 -
Targeted/Planned
Enrollment Format
Page
Targeted/Planned
Enrollment Format
Page.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
PHS 2590 - Enrollment
Report Format Page
Enrollment Report
Format Page.
Grants, Proposals,
Print Proposal
GM_PROP_PRINT_REQ
Administrative Reports
Report ID
Report Name
Description Navigation Run Control Page
GMPER034
Bio sketch
Includes name, address,
education, professional
experience, and
languages. (SQR)
Grants,
Professionals,
Biosketch Report
RUN_GM_PERS_BIO
GMPER035
Current and Pending
Support
An overall picture of the
total commitments for a
particular investigator.
(SQR)
Grants,
Professionals, Other
Support Report
RUN_GM_PERS_BIO
SF-269A
Interim Outlay
Report
Grant report required by
the federal government
for interim outlays on
selected grants that it
awards.
Grants, Reports, SF
269
GM_AWD_RUN_CNTL
SF-272
Federal Cash
Transactions Report
Cash management
report required by the
United States
government. Report can
take two forms,
depending upon whether
the award entails a
Letter of Credit or not.
Grants, Reports, SF
272
GM_AWD2_RUN_CNTL
SF-272A
Federal Cash
Transactions Report
Continuation
Cash management
report required by the
United States
government for
continuation grants.
Grants, Reports, SF
272
GM_AWD2_RUN_CNTL
P E O P L E S O F T 8 . 4 F I N A N C I A L S A N D S U P P L Y C H A I N M A N A G E M E N T P E O P L E B O O K S
1 - 4 P E O P L E S O F T G R A N T S R E P O R T S P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L
Billing Forms
Report ID
Report Name
Description Navigation Run Control Page
SF-1034
Public Voucher for
Purchases and Services
Other Than Personal
Public Voucher for
Purchases and Services
Other Than Personal,
including invoice
summary page with
invoice header
information. (SQR)
Billing, Generate
Invoices, Non-
Consolidated, then
select either:
Single Action
Invoice
Print Pro Forma
Finalize and Print
Invoices
RUN_BI_PRNTIVC
SF-1035
Public Voucher for
Purchases and Services
Other Than Personal –
Continuation
Continuation Sheet on
SF-1034 including
invoice header and
expense line detail
information controlled
by expense account
tree definition. (SQR)
Billing, Generate
Invoices, Non-
Consolidated, then
select either:
Single Action
Invoice
Print Pro Forma
Finalize and Print
Invoices
RUN_BI_PRNTIVC
SF-270
Request for Advance or
Reimbursement
Invoice summary page
including invoice
header information.
(SQR)
Billing, Generate
Invoices, Non-
Consolidated, then
select either:
Single Action
Invoice
Print Pro Forma
Finalize and Print
Invoices
RUN_BI_PRNTIVC
GM_GEN
Generic Letterhead
Invoice
Generic invoice
includes invoice header
and expense line detail
information controlled
by expense account
tree definition. (SQR)
Billing, Generate
Invoices, Non-
Consolidated, then
select either:
Single Action
Invoice
Print Pro Forma
Finalize and Print
Invoices
RUN_BI_PRNTIVC
P E O P L E S O F T 8 . 4 F I N A N C I A L S A N D S U P P L Y C H A I N M A N A G E M E N T P E O P L E B O O K S
P E O P L E S O F T P R O P R I E T A R Y A N D C O N F I D E N T I A L P E O P L E S O F T G R A N T S R E P O R T S 1 - 5
Report ID
Report Name
Description Navigation Run Control Page
BIGIVCPN
Invoice Generation
process
Process that generates
the invoices described
above plus optional
cost sharing and salary
detail (BIGSALDL)
reports. (SQR)
Billing, Generate
Invoices, Non-
Consolidated, then
select either:
Single Action
Invoice
Print Pro Forma
Finalize and Print
Invoices
RUN_BI_PRNTIVC
BIGSALDL
Salary Detail
Provides the salary
detail associated with
invoices that your
system has created.
(SQR)
Billing, Generate
Invoices, Reports,
Salary Detail
RUN_GM_SAL_
DETL
GMLOC01
Letter of Credit
Provides details on
document number and
federal award number
as well as funding,
previously billed,
unbilled, and allowable
draw balances. (SQR)
Billing, Billing
Worksheet, Letter of
Credit Summary
BI_LOC_SUMMARY
APPLICANT ORGANIZATION
DATE
DATE
LEAVE BLANK ---- FOR PHS USE ONLY.
SIGNATURE OF PI / PD NAMED IN 3a.(In ink. "Per" signature not acceptable.)
Type Activity Number
Review Group Formerly
Council/Board (Month, Year) Date Received
RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT
NAME (Last, first, middle)
YES
Number:PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR
3b.
POSITION TITLE MAILING ADDRESS (Street, city, state, zip code)
DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
MAJOR SUBDIVISION
TELEPHONE AND FAX (Area code, number and extension)E-MAIL ADDRESS:
HUMANSUBJECTSRESEARCH
4a. Research Exempt
No
Yes
COSTS REQUESTED FOR PROPOSEDPERIOD OF SUPPORT
If •Yes,• Exemption No.VERTEBRATE ANIMALS
5a. If "Yes," IACUC approval Date
No Yes
5b. Animal welfare assurance no
DATES OF PROPOSED PERIOD OFSUPPORT (month, day, year - MM/DD/YY)
From Through
COSTS REQUESTED FOR INITIALBUDGET PERIOD
Direct Costs ($) Total Costs ($) Direct Costs ($) Total Costs ($)
TYPE OF ORGANIZATIONPublic: Federal State Local
Private: Private Nonprofit
Forprofit:
Woman-owned Socially and Economically Disadvantaged
ENTITY IDENTIFICATION NUMBER
Congressional District
ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
DUNS NO. (if available)
14. PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: Icertify that the statements herein are true, complete and accurate to the best ofmy knowledge. I am aware that any false, fictitious, or fraudulent statements orclaims may subject me to criminal, civil, or administrative penalties. I agree toaccept responsibility for the scientific conduct of the project and to provide therequired progress reports if a grant is awarded as a result of this application.15. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: Icertify that the statements herein are true, complete and accurate to the best ofmy knowledge, and accept the obligation to comply with Public Health Servicesterms and conditions if a grant is awarded as a result of this application. I amaware that any false, fictitious, or fraudulent statements or claims may subjectme to criminal, civil, or administrative penalties.
SIGNATURE OF OFFICIAL NAMED IN 13. (In ink. "Per" signature not acceptable.)
DEGREE(S)
Name
Title
Address
Tel Fax
New Investigator YES
TEL: FAX:
11.
1.
2.
3.
3a.
4b. Human SubjectsAssurance No.
3c. 3d.
3e.
3f.
3g.
4. 5.
General
6. 7.
7a. 7b.
8.
8a. 8b.
9. 10.
13.
Grant Application
Department of Health and Human Services Public Health Service
12.
TITLE OF PROJECT
Title:
Name
Title
Address
Tel Fax
Name
Address
Do not exceed 56-character length restrictions, including spaces.
PHS 398 (Rev. 05/01) Face Page
4c. NIH-defined Phase IIIClinical Trial
NO
No
Small Business
Yes
(If "Yes," state number and title)NO
No Yes
Form Page 1
OMB No 0925-0001Form Approved Through 05/2004
Test Proposal 1X
Human Resources
09/12/2001 09/12/2005
X
X
X
X
$805,000 $805,000
Peoplesoft University
1234
X
A000245
1500 Grant AveSan Francisco, CA 94127USA
Human Resources
925 6947275
Sherwood,Douglas
$800,000 $800,000
KEY PERSONNEL. See instructions. Use continuation pages as needed to provide the required information in the format shown below. Start with Principal Investigator. List all other key personnel in alphabetical order, last name first.
Role on ProjectName
Disclosure Permission Statement. Applicable to SBIR/STTR Only. See instructions.
PHS 398 (Rev. 05/01)
Organization
PERFORMANCE SITE(S) (organization, city, state)
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
Page ______
DESCRIPTION: State the application•s broad, long-term objectives and specific aims, making reference to the health relatedness of the project. Describeconcisely the research design and methods for achieving these goals. Avoid summaries of past accomplishments and the use of the first person. Thisabstract is meant to serve as a succinct and accurate description of the proposed work when separated from the application. If the application is funded,this description, as is, will become public information. Therefore, do not include proprietary/confidential information. DO NOT EXCEED THE SPACEPROVIDED.
Form Page 2
Yes No
Sherwood,Douglas Org 1 PIAngelini,Gina Org 2 Co-PIUnger,Randy Org 3 Key
X
Sherwood,Douglas
The name of the principal investigator/program director must be provided at the top of each printed page and each continuation page.
RESEARCH GRANT
TABLE OF CONTENTS
Page Numbers
Research Plan
.....................................................................................................
Protection of Human Subjects (Required if Item 4 on the Face Page is marked •Yes•)
Inclusion of Women (Required if Item 4 on the Face Page is marked •Yes•)
trial is proposed
F. Vertebrate Animals
G. Literature CitedH. Consortium/Contractual Arrangements
I. Consultants
Checklist
Check ifAppendix isincluded
1
Table of Contents
Budget for Entire Proposed Period of Support
Detailed Budget for Initial Budget Period
Introduction to Revised Application (Not to exceed 3 pages)
Introduction to Supplemental Application (Not to exceed 1 page)
Appendix (Five collated sets. No page numbering necessary for Appendix.)
Number of publications and manuscripts accepted or submitted for publication (not to exceed 10) ___________
Other items (list):
.................................................................................................................
........................................................................................................
............................................................................
Inclusion of Minorities (Required if Item 4 on the Face Page is marked •Yes•)
.................................................................................................
.......................................
........................................
........................................................
............................................................
Budgets Pertaining to Consortium/Contractual Arrangements
PHS 398 (Rev. 05/01) Page ______
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
J. Product Development Plan (SBIR/STTR Phase II and Fast-Track ONLY)
2-
Form Page 3
Biographical Sketch -- Principal Investigator/Program Director (Not to exceed four pages)
Other Biographical Sketches (Not to exceed four pages for each)
Resources
Face Page ..............................................................................................................
...........................................................................
....................................................................
..................................................
.......................
.................................................
.....................................................................................................
...............................................................................................................
Description, Performance Sites, and Personnel ...................................................................
..............................................
Data and Safety Monitoring Plan (Required if Item 4 on the Face Page is marked •Yes• and a Phase I, II, or III clinical
Inclusion of Children (Required if Item 4 on the Face Page is marked •Yes•) ........................................
..............................................................................................
B. Background and Significance
C. Preliminary Studies/Progress Report/ Phase I Progress Report (SBIR/STTR Phase II ONLY)
(Items A-D: not to exceed 25 pages*)* SBIR/STTR Phase I: Items A-D limited to 15 pages.
......................................................................................................
E. Human Subjects
A. Specific Aims
...................................................................................................
D. Research Design and Methods .....................................................................................
......................................................................................
Appendices NOT PERMITTED for Phase I SBIR/STTR unless specifically solicited.
{}
Sherwood,Douglas
PERSONNEL (Applicant organization only)
NAME
FROM THROUGHDETAILED BUDGET FOR INITIAL BUDGET PERIOD
DIRECT COSTS ONLY
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTSINPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
CONSORTIUM/CONTRACTUAL
COSTS
DIRECT COSTS
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)
FACILITIES AND ADMINISTRATION COSTS
ROLE ONPROJECT
SUBTOTALS
%EFFORT
ON PROJ.
INST.BASE
SALARY
DOLLAR AMOUNT REQUESTED (omit cents)
SALARYREQUESTED
FRINGEBENEFITS TOTALS
PHS 398 (Rev. 05/01)
TYPEAPPT.
(months)
SBIR/STTR Only: FEE REQUESTED
$
$
Page ______
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
Form Page 4
$0 $0 $0
$40,000
$0
$0
$0$0$0
$0
$0
$0
$0$0
40,000
Sherwood,Douglas
09/12/2001 09/11/2002
40,000
BUDGET FOR ENTIRE PROPOSED PERIOD OF SUPPORTDIRECT COSTS ONLY
BUDGET CATEGORYTOTALS
INITIAL BUDGETPERIOD
(from Form Page 4)
ADDITIONAL YEARS OF SUPPORT REQUESTED
2nd 3rd 4th 5th
PERSONNEL: Salary and fringebenefitsApplicant organization only
CONSULTANT COSTS
EQUIPMENT
SUPPLIES
TRAVEL
PATIENTCARECOSTS
INPATIENT
OUTPATIENT
ALTERATIONS ANDRENOVATIONS
OTHER EXPENSES
SUBTOTAL DIRECT COSTS
DIRECT
F & A
CONSORTIUM/CONTRACTUALCOSTS
TOTAL DIRECT COSTS
TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD (Item 8a, Face Page)
JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.
$
PHS 398 (Rev. 05/01) Page ______
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
Form Page 5
SBIR/STTR Only Fee RequestedSBIR/STTR Only: Total Fee Requested for Entire Proposed Project Period(Add Total Fee amount to •Total direct costs for entire proposed project period• above and Total F&A/indirect costs fromChecklist Form Page, and enter these as •Costs Requested for Proposed Period of Support on Face Page, Item 8b.)
$
$0
$40,000
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$40,000
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Period: 1Consultant Services (Both)
Sherwood,Douglas
$40,000
40,000
Initial Budget Period Second Year of Support Third Year of Support Fourth Year of Support Fifth Year of Support
BUDGET JUSTIFICATION PAGE:MODULAR RESEARCH GRANT APPLICATION
Total Direct Costs Requested for Entire Project Period
PHS 398 (Rev. 05/01)Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 3b.
Page ______ Modular Budget Format Page
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
$40,000 $0 $0 $0
$40,000
Sherwood,Douglas
BIOGRAPHICAL SKETCHProvide the following information for the key personnel in the order listed for Form Page 2.
Follow this format for each person. DO NOT EXCEED FOUR PAGES.
NAME POSITION TITLE
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)
DEGREE(if applicable) YEAR(s) FIELD OF STUDY
PHS 398 (Rev. 05/01)
INSTITUTION AND LOCATION
Page ______
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
Biographical Sketch Format Page
NOTE: The Biographical Sketch may not exceed four pages. Items A and B (together) may not exceed two ofthe four-page limit. Follow the formats and instructions on the attached sample.
A. Positions and Honors. List in chronological order previous positions, concluding with your present position. Listany honors. Include present membership on any Federal Government public advisory committee.
B. Selected peer-reviewed publications (in chronological order). Do not include publications submitted or inpreparation.
C. Research Support. List selected ongoing or completed (during the last three years) research projects (federaland non-federal support). Begin with the projects that are most relevant to the research proposed in this application.Briefly indicate the overall goals of the projects and your role (e.g. PI, Co-Investigator, Consultant) in the researchproject. Do not list award amounts or percent effort in projects.
Sherwood,Douglas
Experience:
Honors:
2001 - Best PI of the year award, Georgetown
Memberships:
Publications:
Sherwood,Douglas
! Principal Investigator/Program Director (Last, first, middle):
# PHS 398 (Rev. 05/01) Page _______ Resources Format Page #
RESOURCES FACILITIES: Specify the facilities to be used for the conduct of the proposed research. Indicate the performance sites and describe capacities, pertinent capabilities, relative proximity, and extent of availability to the project. Under “Other,” identify support services such as machine shop, electronics shop, and specify the extent to which they will be available to the project. Use continuation pages if necessary. Laboratory: Clinical: Animal: Computer: Office: Other:
MAJOR EQUIPMENT: List the most important equipment items already available for this project, noting the location and pertinent capabilities of each.
a. Initial budget period:
CHECKLISTTYPE OF APPLICATION (Check all that apply.)
NEW application. (This application is being submitted to the PHS for the first time.)
COMPETING CONTINUATION of grant number:
(This application is to extend a funded grant beyond its current project period.)
DHHS Agreement dated:___________________________________________
(This application is for additional funds to supplement a currently funded grant.)
CHANGE of principal investigator/program director.
Name of former principal investigator/program director:
FOREIGN application or significant foreign component.
INVENTIONS AND PATENTS (Competing continuation appl. and Phase II only)
Yes. If "Yes," Not previously reported
All applications must indicate whether program income is anticipated during the period(s) for which grant support is request. If program income is anticipated, use the format below to reflect the amount and source(s).
2. ASSURANCES/CERTIFICATIONS (See instructions.)
Amount of base $ ___________________x Rate applied __________ % = F&A costs $ _________________
Budget Period Anticipated Amount Source(s)
The following assurances/certifications are made and verified by thesignature of the Official Signing for Applicant Organization on the FacePage of the application. Descriptions of individual assurances/ certificationsare provided in Section III. If unable to certify compliance, whereapplicable, provide an explanation and place it after this page. •HumanSubjects; •Research Using Human Embryonic Stem Cells• •Research onTransplantation of Human Fetal Tissue •Women and Minority InclusionPolicy •Inclusion of Children Policy• Vertebrate Animals•
•Debarment and Suspension; •Drug- Free Workplace (applicable to new[Type 1] or revised [Type 1] applications only); •Lobbying; •Non-Delinquency on Federal Debt; •Research Misconduct; •Civil Rights (FormHHS 441 or HHS 690); •Handicapped Individuals (Form HHS 641 or HHS690); •Sex Discrimination (Form HHS 639-A or HHS 690); •AgeDiscrimination (Form HHS 680 or HHS 690); •Recombinant DNA andHuman Gene Transfer Research; •Financial Conflict of Interest (exceptPhase I SBIR/STTR) •STTR ONLY: Certification of Research InstitutionParticipation.
No Facilities and Administration Costs Requested.
DHHS Agreement being negotiated with ___________________________________________ Regional Office.
Yes
No Previously reported
3. FACILITIES AND ADMINSTRATIVE COSTS (F&A)/ INDIRECT COSTS. See specific instructions.
1. PROGRAM INCOME (See instructions.)
CALCULATION* (The entire grant application, including the Checklist, will be reproduced and provided to peer reviewers as confidential information.)
4. SMOKE-FREE WORKPLACE
No DHHS Agreement, but rate established with ________________________________________________ Date __________________
SUPPLEMENT to grant number:
________________________________________________________________
____________________________
______________________________________________
PHS 398 (Rev. 05/01)
____________________________________________
(This application replaces a prior unfunded version of a new, competing continuation, or supplemental application.)
Amount of base $ ___________________x Rate applied __________ % = F&A costs $ _________________
*Check appropriate box(es):
Salary and wages base
Off-site, other special rate, or more than one rate involved (Explain)
Modified total direct cost base
Explanation (Attach separate sheet, if necessary.):
Other base (Explain)
Page ______
No (The response to this question has no impact on the review or funding of this application.)
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
Checklist Form Page
STTR Phase I
REVISION of application number:
SBIR Phase I
STTR Phase II: STTR Phase I Grant No. _ ______________________
SBIR Phase II: SBIR Phase I Grant No. _ ______________________
STTR Fast Track
SBIR Fast Track
b. 02 year
TOTAL F&A Costs $
c. 03 year Amount of base $ ___________________x Rate applied __________ % = F&A costs $ _________________
Amount of base $ ___________________x Rate applied __________ % = F&A costs $ _________________d. 04 year
e. 05 year Amount of base $ ___________________x Rate applied __________ % = F&A costs $ _________________
X
X 12/15/1997
0
X
Sherwood,Douglas
See Attached...
See Attached...
See Attached...
See Attached...See Attached...
Place this form at the end of the signed originalcopy of the application. Do not duplicate.
PERSONAL DATA ONPRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR
The Public Health Service has a continuing commitment to monitor the operation of its review and awardprocesses to detect•and deal appropriately with•any instances of real or apparent inequities with respect toage, sex, race, or ethnicity of the proposed principal investigator/program director. To provide the PHS with theinformation it needs for this important task, complete the form below and attach it to the signed original of theapplication after the Checklist. Do not attach copies of this form to the duplicated copies of theapplication.
Female Male
Hispanic or Latino. A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture ororigin, regardless of race. The term, •Spanish origin,• can be used in addition to •Hispanic or Latino.•
American Indian or Alaska Native. A person having origins in any of the original peoples of North, Central, or SouthAmerica, and who maintains tribal affiliation or community attachment.
Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent,including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, andVietnam. (Note: Individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collectionstrategies.)
Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as •Haitian• or•Negro• can be used in addition to •Black• or African American.•
Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa,or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Check here if you do not wish to provide some or all of the above information.
DATE OF BIRTH (MM/DD/YY)
PHS 398 (Rev. 05/01) DO NOT NUMBER THIS FORM
SEX/GENDER
Hispanic or Latino
Principal Investigator/Program Director (Last, first, middle) :____________________________________________
Social Security No.
2. What race do you consider yourself to be? Select one or more of the following.
1. Do you consider yourself to be Hispanic or Latino? (See definition below.) Select one.
RACE
ETHNICITY
Not Hispanic or Latino
Upon receipt of the application by the PHS, this form will be separated from the application. This form will notbe duplicated, and it will not be a part of the review process. Data will be confidential, and will be maintainedin Privacy Act record system 09-25-0036, •Grants: IMPAC (Grant/Contract Information).• The PHS requestssocial Security numbers for accurate identification, referral, and review of applications and for management ofPHS grant programs. Provision of the Social Security number is voluntary. No individual will be denied anyright, benefit, or privilege provided by law because of refusal to disclose his or her Social Security Number.The PHS requests the Social Security Number under Sections 301 (a) and 487 of the PHS Act as amended(42 USC214a and USC288). All analyses conducted on the date of birth and race and/or ethnic origin data willreport aggregate statistical findings only and will not identify individuals. If you decline to provide thisinformation, it will in no way affect consideration of your application. Your cooperation will be appreciated.
Personal Data Form Page
Sherwood,Douglas
PHS 398 (Rev. 05/01)Number pages consecutively at the bottom throughout the application. Do not use suffixes such as 3a, 3b.
Page ______
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Principal Investigator/Program Director (Last, first, middle) :____________________________________________Sherwood,Douglas
! Principal Investigator/Program Director (Last, first, middle):
# PHS 398/2590 (Rev. 05/01) Page _______ Targeted/Planned Enrollment Format Page #
Targeted/Planned Enrollment Table This report format should NOT be used for data collection from study participants.
Study Title: Total Planned Enrollment:
TARGETED/PLANNED ENROLLMENT: Number of Subjects
Sex/Gender Ethnic Category
Females Males Total
Hispanic or Latino
Not Hispanic or Latino
Ethnic Category Total of All Subjects*
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects * *The “Ethnic Category Total of All Subjects” must be equal to the “Racial Categories Total of All Subjects.”
! Principal Investigator/Program Director (Last, first, middle):
# PHS 398/2590 (Rev. 05/01) Page _______ Inclusion Enrollment Report Format Page #
Inclusion Enrollment Report Table This report format should NOT be used for data collection from study participants.
Study Title: Total Enrollment: Protocol Number: Grant Number:
PART A. TOTAL ENROLLMENT REPORT: Number of Subjects Enrolled to Date (Cumulative) by Ethnicity and Race
Sex/Gender Ethnic Category
Females Males Unknown or Not Reported Total
Hispanic or Latino ** Not Hispanic or Latino
Unknown (Individuals not reporting ethnicity)
Ethnic Category: Total of All Subjects* *Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More than one race
Unknown or not reported
Racial Categories: Total of All Subjects* * PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative)
Racial Categories Females Males Unknown or Not Reported Total
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More Than One Race
Unknown or not reported
Racial Categories: Total of Hispanics or Latinos** *** These totals must agree. ** These totals must agree.
Principal Investigator/Program Director: (Last, first, middle)
# PHS 398 (Rev. 05/01) Page _____ Other Support Format Page #
DO NOT SUBMIT UNLESS REQUESTED OTHER SUPPORT
There is no "form page" for other support. Information on other support should be provided in the format shown below, using continuation pages as necessary. Include the principal investigator's name at the top and number consecutively with the rest of the application. The sample is intended to provide guidance regarding the type and extent of information requested. Refer to the specific instructions in Section I. For information pertaining to the use of and policy for other support, see “Policy and Additional Guidance.”
Format NAME OF INDIVIDUAL ACTIVE/PENDING Project Number (Principal Investigator) Source Title of Project (or Subproject) The major goals of this project are…
Dates of Approved/Proposed Project Annual Direct Costs
Percent Effort
OVERLAP (summarized for each individual) Samples
ANDERSON, R.R. ACTIVE
2 R01 HL 00000-13 (Anderson) 3/1/1997 – 2/28/2002 30% NIH/NHLBI $186,529 Chloride and Sodium Transport in Airway Epithelial Cells
The major goals of this project are to define the biochemistry of chloride and sodium transport in airway epithelial cells and clone the gene(s) involved in transport.
5 R01 HL 00000-07 (Baker) 4/1/1994 – 3/31/2002 10% NIH/NHLBI $122,717 Ion Transport in Lungs
The major goal of this project is to study chloride and sodium transport in normal and diseased lungs.
R000 (Anderson) 9/1/1996 – 8/31/2002 10% Cystic Fibrosis Foundation $43,123 Gene Transfer of CFTR to the Airway Epithelium
The major goals of this project are to identify and isolate airway epithelium progenitor cells and express human CFTR in airway epithelial cells.
PENDING DCB 950000 (Anderson) 12/01/2002 – 11/30/2004 20% National Science Foundation $82,163 Liposome Membrane Composition and Function
The major goals of this project are to define biochemical properties of liposome membrane components and maximize liposome uptake into cells.
OVERLAP
Principal Investigator/Program Director: (Last, first, middle)
# PHS 398 (Rev. 05/01) Page _____ Personnel Report Format Page #
DO NOT SUBMIT UNLESS REQUESTED Competing Continuation Applications
PERSONNEL REPORT All Key Personnel for the Current Budget Period
Name Degree(s) SSN Role on Project (e.g. PI, Res. Assoc.)
Date of Birth (MM/DD/YY)
Annual % Effort
TELEPHON
ENTITY IDENTIFICATION NUMBER
Corrections to Page 1 Face Page
Requested Budgt Period
TITLE OF PROJECT
PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR(Name and address, street, city, state, zip code)
E-MAIL ADDRESS
DIRECT $
MAJOR SUBDIVISION
6
No Yes
DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
E-MAIL ADDRESS
Research ExemptVERTEBRATE AIMALSNo
YesIf "Yes," IACUC approvaldate
Animal Welfare Assurance no.
INVENTIONS AND PATENTS
Not previously reported
TELEPHON
FAX
Full IRB or
6c.
{COSTS REQUESTED FOR NEXT BUDGET PERIOD
11a.
TOTAL $
PERFORMANCE SITE(S) (Organizations and addresses)
NAME OF ADMINISTRATIVEOFFICIAL (Item 5)
NIH-Defined Phase III
Total Project Period
IRB approval date
No
NAME AND TITLE OF OFFICIAL SIGNING FOR APPLICANT ORGANIZATION (Item 14)
PRINCIPAL INVESTIGATOR ORPROGRAM DIRECTOR (Item 2a)
11c.
E-MAIL ADDRESS
Review Group Type Grant Number
2b.
1.
2a. 3.
2c.
2d.
4.
5. TITLE AND ADDRESS OF ADMINISTRATIVE OFFICIAL
FAX
7a.
7.
8
7b.
9a.
12.
8b.9.
10.
11b.
6a. Human Subjects Assurance No.6b.
APPLICANT ORGANIZATION (Name and address, street, city, state, zip code)
Department of Health and Human ServicesPublic Health Service
Grant Progress Report
HUMAN SUBJECTS
Expedited Review
Yes If "Yes," Previously reported
SIGNATURE OF OFFICIAL NAMED IN 11(In ink. "Per" signature not acceptable.)
DATE
DATE
14.
PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE: I certify that thestatements herein are true, complete and accurate to the best of my knowledge. I amaware that any false, fictitious, or fraudulent statements or claims may subject me tocriminal, civil, or administrative penalties. I agree to accept responsibility for the scientificconduct of the project and to provide the required progress reports if a grant is awardedas a result of this application.
SIGNATURE OF PI/PD NAMED IN 2a(In ink. "Per" signature not acceptable.)
13.
APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that thestatements herein are true, complete and accurate to the best of my knowledge, andaccept the obligation to comply with Public Health Service terms and conditions if a grantis awarded as a result of this application. I am aware that any false, fictitious, or fraudulentstatements or claims may subject me to criminal, civil, or administrative penalties.
Activity
PHS 2590 (Rev. 05/01) Face Page
From: Through:
From: Through:
If Not Exempt ("No" in 6a.)
NAME
Clinical TrialIf Exempt ("Yes" in 6a):Exemption no.
TELEPHON
No
NoYes Yes
FAX
TITLE
(
(
(
(
(
(
)
)
)
)
)
)
Form Page 1
09/12/2001 09/12/2005
09/12/2001 09/11/2002
Test Proposal 1
Sherwood,Douglas
Human Resources
Human Resources
Peoplesoft University1500 Grant AveSan Francisco, CA 94127USA
1234
XX
X
X
0 0X
925 6947275
Form Approved Through 5/2004OMB No. 0925-0001
Sherwood,Douglas
• Principal Investigator/Program Director (Last, first, middle):
! PHS 2590 (Rev. 05/01) Page _______ Form Page 2 !!!!
DETAILED BUDGET FOR NEXT BUDGET PERIOD – DIRECT COSTS ONLY
FROM
THROUGH
GRANT NUMBER
PERSONNEL (Applicant organization only) DOLLAR AMOUNT REQUESTED (omit cents) NAME ROLE ON PROJECT
TYPE APPT.
(months)
% EFFORT
ON PROJ.
SALARY REQUESTED
FRINGE BENEFITS
TOTALS
Principal Investigator
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
INPATIENT PATIENT CARE COSTS
OUTPATIENT ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
SUBTOTAL DIRECT COSTS FOR NEXT BUDGET PERIOD
DIRECT COSTS CONSORTIUM/CONTRACTUAL COSTS
FACILITIES AND ADMINISTRATIVE COSTS
TOTAL DIRECT COSTS FOR NEXT PROJECT PERIOD (Item 9a, Face Page)
Provide a detailed budget justification for those line items and amounts which represent a significant change from that previously recommended. Usecontinuation pages if necessary.
CURRENT BUDGET PERIOD
GRANT NUMBER
FROM THROUGH
BUDGET JUSTIFICATION
PHS 2590 (Rev. 05/01)
Explain any estimated unobligated balance (including prior year carryover) that is greater than 25% of the current year's total budget.
Page ___ Form Page 3
09/12/2001 09/11/2002
! Principal Investigator/Program Director (Last, first, middle):
" PHS 398/2590 (Rev. 05/01) Page _______ Biographical Sketch Format Page "
BIOGRAPHICAL SKETCH Provide the following information for the key personnel in the order listed for Form Page 2.
Follow the sample format for each person. DO NOT EXCEED FOUR PAGES.
NAME
POSITION TITLE
EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)
INSTITUTION AND LOCATION DEGREE (if applicable)
YEAR(s) FIELD OF STUDY
FROM
PROGRESS REPORT SUMMARY
PRINCIPAL INVESTIGATOR OR PROGRAM DIRECTOR
APPLICANT ORGANIZATION
TITLE OF PROJECT (Repeat title shown in Item 1 on first page )
(SEE INSTRUCTIONS)
Human Subjects (Complete Item 7 on the Face Page)Involvement of Human Subjects Change
Vertebrate Animals (Complete Item 8 on the Face Page)Use of Vertebrate Animals Change
PERIOD COVERED BY THIS REPORT
THROUGH
B.
A.
PHS 2590 (Rev. 05/01)
GRANT NUMBER
Page ___
No Change Since Previous Submission
No Change Since Previous Submission
WOMEN AND MINORITY INCLUSIONSee PHS 398 Instructions. Use Inclusion Enrollment Report Format Page and, if necessary, Targeted/Planned Enrollment Format Page.
Form Page 5
Peoplesoft University
Test Proposal 1
09/12/2001 09/11/2002
X
X
Has there been a change in the other support of key personnel since the last reporting period?TEST
Will there be, in the next budget period, significant rebudgeting of funds from what was approved for this project?TEST3
Project Description: Test Proposal 1
Sherwood,Douglas
Budget Period
DHHS Agreement dated:____________________________________________
1. PROGRAM INCOME (See Instructions.)All applications must indicate whether program income is anticipated during the period(s) for which grant support is requested. If program income isanticipated, use the format below to reflect the amount and source(s).
Anticipated Amount
*Check appropriate box(es):
Salary and wages base
The following assurances/certifications are made and verified by thesignature of the Official Signing for Applicant Organization on the Face Pageof the application. Descriptions of individual assurances/ certifications areprovided in Section III of the PHS 398. If unable to certify compliance, whereapplicable, provide an explanation and place it after this page. •Human Subjects •Research Using Human Pluripotent Stem Cells•Research on Transplantation of Human Fetal Tissue •Women and MinorityInclusion Policy •Inclusion of Children Policy• Vertebrate Animals
•Debarment and Suspension •Drug- Free Workplace (applicable to new[Type 1] or revised [Type 1] applications only); •Lobbying •Non-Delinquencyon Federal Debt •Research Misconduct •Civil Rights (Form HHS 441 orHHS 690); •Handicapped Individuals (Form HHS 641 or HHS 690) •SexDiscrimination (Form HHS 639-A or HHS 690) •Age Discrimination (FormHHS 680 or HHS 690); •Recombinant DNA and Human Gene TransferResearch •Financial Conflict of Interest (except Phase I SBIR/STTR) •STTRONLY: Certification of Research Institution Participation.
Off-site, other special rate, or more than one rate involved (Explain below)
No F&A Costs Requested.
No DHHS Agreement, but rate established with ________________________________________________
Amount of base $ _____________________ x Rate applied _______ % = F&A costs $ ________________Entire proposed budget period:
Add to total direct costs from form page 2 and enter new total on FACE PAGE, Item 9b.
CALCULATION*
CHECKLIST
GRANT NUMBER
Date __________________
2. ASSURANCES/CERTIFICATIONS (See instructions.)
PHS 2590 (Rev. 05/01)
Source(s)
Modified total direct costs base
Explanation (Attach separate sheet, if necessary.):
Other base (Explain below)
Page ___
3. FACILITIES AND ADMINSTRATIVE (F&A) COSTSIndicate the applicant organization•s most recent F&A cost rate establishedwith the appropriate DHHS Regional Office, or, in the case of for-profitorganizations, the rate established with the appropriate PHS Agency CostAdvisory Office.
F&A costs will not be paid on construction grants, grants to Federalorganizations, grants to individuals, and conference grants. Follow anyadditional instructions provided for Research Career Awards, InstitutionalNational Research Service Awards, Small Business InnovationResearch/Small Business Technology Transfer Grants, foreign grants, andspecialized grant applications.
Form Page 6
X 12/15/1997
See Attached...
Name Degree(s) SSN Date of Birth(MM/DD/YY)
Annual% Effort
Role on Project(e. g., Pl, Res. Assoc.)
PERSONNEL REPORT GRANT NUMBER
PHS 2590 (Rev. 05/01)
Place this form at the end of the signed original copy of the applicaiton. Do not duplicate.
All Key Personnel for the Current Budget Period
Page ___ Form Page 7
F & A Rate Type Amount of base RateApplied F & A costs
FACILITIES AND ADMINISTRATION COSTS FOR ENTIRE PROPOSED PROJECT PERIOD
F & A BaseBudgetPeriodProject # Effective
Date
PHS 2590 (Rev. 05/01)
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GRANT NUMBER:_____________________________________________________
Page ________
! Principal Investigator/Program Director (Last, first, middle):
# PHS 398/2590 (Rev. 05/01) Page _______ Targeted/Planned Enrollment Format Page #
Targeted/Planned Enrollment Table This report format should NOT be used for data collection from study participants.
Study Title: Total Planned Enrollment:
TARGETED/PLANNED ENROLLMENT: Number of Subjects
Sex/Gender Ethnic Category
Females Males Total
Hispanic or Latino
Not Hispanic or Latino
Ethnic Category Total of All Subjects*
Racial Categories
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects * *The “Ethnic Category Total of All Subjects” must be equal to the “Racial Categories Total of All Subjects.”
Principal Investigator/Program Director (Last, first, middle):_______________________________________
Inclusion Enrollment ReportThis report format should NOT be used for data collection from study participants.
Total Enrollment:
Study Title:
PART A. TOTAL ENROLLMENT REPORT: Number of Subjects Enrolled to Date (Cumulative) by Ethnicity and Race
TOTALS
Hispanic or Latino
Ethnic CategorySex/Gender
Females Unknown or Not Reported
Not Hispanic or Latino
Ethnic Category Total of All Subjects*
Grant Number:
Protocol Number:
Males
Unknown (Individuals not reporting ethnicity)
**
*
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects **
Racial Categories
More than one race
Unknown or not reported
**
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Racial Categories: Total of All Subjects *
Racial Categories
More than one race
Unknown or not reported
*
PHS 2590 (Rev. 05/01) Page ___
* These totals must agree.** These totals must agree.
PART B. HISPANIC ENROLLMENT REPORT: Number of Hispanics or Latinos Enrolled to Date (Cumulative)
Females Males Unknown or Not Reported TOTALS
Inclusion Enrollment Report Format Page
0
0
0
0
0
0
0
0 0 0 0
0
0
0 0 0 0
0
0 0 0 0
Sherwood,Douglas
Standard Form 1034 (EG)
Department of the Treasure
1 TFM 4-2000
1034-121
PUBLIC VOUCHER FOR PURCHASES ANDSERVICES OTHER THAN PERSONAL
VOUCHER NO.
U.S. DEPARTMENT. BUREAU, OR ESTABLISHMENT LOCATION DATE VOUCHER PREPARED
CONTRACT NUMBER AND DATE
REQUISITION NUMBER AND DATE
SCHEDULE NO.
PAID BY
DATE INVOICE RECEIVED
DISCOUNT TERMS
PAYEE'S ACCOUNT NUMBER
PAYEE'S
NAME
AND
ADDRESS
SHIPPED FROM TO WEIGHT GOVERNMENT B/L NUMBER
NUMBER
AND DATE
OF ORDER
DATE OF
DELIVERY
OR SERVICE
ARTICLES OR SERVICES
(Enter description, item number of contract or Federal
supply schedule, and other information deemed necessary)
QUANTITY
UNIT PRICE
COST PER
AMOUNT
(1)
(Use continuation sheet(s) if necessary) (Payee must NOT use the space below) TOTAL
APPROVED FOR EXCHANGE RATE DIFFERENCE
S= $ = $1.00
BY 2
Amount verified; correct for
TITLE (Signature or initials)
PAYMENT:
PROVISIONAL
COMPLETE
PARTIAL
FINAL
PROGRESS
ADVANCE
Pursuant to authority vested in me, I certify that this voucher is correct and proper for payment.
(Date) (Authorized Certifying Officer) 2 (Title)
ACCOUNTING CLASSIFICATION
P
A
I
D
CHECK NUMBER ON ACCOUNT OF U.S. TREASURY CHECK NUMBER ON (Name of bank)
CASH DATE PAYEE 3
$
1 When stated in foreign currency, insert name of currency.
2 If ability to certify and authority to approve are combined in one person, one signature only is necessary; otherwise approving officer will sign in space provided, over official title.
3 When a voucher is receipted in the name of a company or coporation, the name of the person writing the company or corporate name, as well as
the capacity in which he signs, must appear. For example: "John Doe Company, per John Smith, Secretary", or "Treasurer", as the case may be.
PER
TITLE
INVOICE
PC-00020945 04
02/12/2002
ref awd num
$555.55
$555.55
Albert Eastmoore
Florence Garden
Sheila Grady
2710 Mission street
Portland OR 97232
United States
USA BANK
111 Montgomery Street
Ste 111
San Francisco CA 94601
United States
Award: NIH002
Standard Form 1035 (EG)
4 Treasury FRM 2000
1035-110
PUBLIC VOUCHER FOR PURCHASES ANDSERVICES OTHER THAN PERSONAL
CONTINUATION SHEET
VOUCHER NO.
SCHEDULE NO.
SHEET NO.
U.S. DEPARTMENT, BUREAU, OR ESTABLISHMENT
NUMBER
AND DATE
OF ORDER
DATE OF
DELIVERY
OR SERVICE
ARTICLES OR SERVICES
(Enter description, item number of contract or Federal
supply schedule, and other information deemed necessary)
QUANTITY
UNIT PRICE
COST PER
AMOUNT
INVOICE
PC-00020945 04
Invoice Date: 02/12/2002Sponsor Award: ref awd numAward Period: 10/01/2001 -09/30/2006Award Amount: $1,500,000.00
USA BANK
111 Montgomery Street
Ste 111
San Francisco CA 94601
United States
Bill Amount
Description 02/01/2002 Thru 02/28/2002 Cumulative Amount
Facilities and Administratio 0.00 1,600.00
TDC 555.55 1,504,555.55
SUBTOTAL: 555.55 1,506,155.55
TOTAL AMOUNT DUE : 555.55
REQUEST FOR ADVANCEOR REIMBURSEMENT
(see instructions)
Approved by Office of Management and
Budget, No. 80-R0183
1.
TYPE OF
PAYMENT
REQUESTED
a. "X" one, or both boxes
ADVANCE REIMBURSEMENT X
b. "X" the applicable box
FINAL PARTIAL
Page of
1 1 pages
2. BASIS OF REQUEST
CASH
ACCRUAL
3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL
ELEMENT TO WHICH THIS REPORT IS SUBMITTED
4. FEDERAL GRANT OR OTHER IDENTIFYING
NUMBER ASSIGNED BY FEDERAL AGENCY
5. PARTIAL PAYMENT REQUEST
NUMBER FOR THIS REQUEST
6. EMPLOYER IDENTIFICATION
NUMBER
7. RECIPIENT'S ACCOUNT NUMBER
OR IDENTIFYING NUMBER
8. PERIOD COVERED BY THIS REQUEST
FROM (month, day, year) TO (month, day, year)
9. RECIPIENT ORGANIZATION 10. PAYEE (Where check is to be sent if different than item 9)
11. COMPUTATION OF AMOUNT OF REIMBURSEMENT/ADVANCES REQUESTED
PROGRAMS/FUNCTIONS/ACTIVITIES (a) (b) (c) TOTAL
(As of Date)
a. Total program outlays to date $ $ $
b. Less: Cumulative program income
c. Net program outlays (Line a minus line b)
d. Estimated net cash outlays for advance period
e. Total (Sum of lines c & d)
f. Non-Federal share of amount on line e
g. Federal share of amount on line e
h. Federal payments previously requested
i. Federal share now requested (Line g minus line h)
j. Advances required by
month, when requested 1st month
by Federal grantor
agency for use in making 2nd month
prescheduled advances
3rd month
12. ALTERNATIVE COMPUTATION FOR ADVANCES ONLY
a. Estimated Federal cash outlays that will be made during period covered by the advance
b. Less: Estimated balance of Federal cash on hand as of beginning of advance period
c. Amount requested (Line a minus line b)
13. CERTIFICATION
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
TYPED OR PRINTED NAME AND TITLE
I certify that to the best of my knowledge and belief the
data above are correct and that all outlays were made in
accordance with the grant conditions or other agreements and
that payment is due and has not been previously requested.
DATE REQUEST SUBMITTED
Phone (Area Code, No., Ext.)
PC-00020945 04
02/12/2002
02/01/2002 02/28/200264931 NIH002
1,506,155.55
0.00
1,506,155.55
0.00
X
X
1,506,155.55
0.00
1,506,155.55
1,505,600.00
555.55
Albert Eastmoore 555 5378822
USA BANK
111 Montgomery Street
Ste 111
San Francisco CA 94601
Florence Garden ref awd num
PeopleSoft BIINVOICE PRINT SUMMARY - SELECTED BILLS
Report ID: BIGIVCPN Page No. 1
Report Action: INVOICE Run Date 02/12/2002
Run Time 18:28:29
Business Unit Number of Bills Total Invoice Amount Currency
EGV05 1 555.55 USD
Total number of bills printed: 1