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Form Approved Through 11/30/2010 OMB No. 0925-0001

Department of Health and Human Services Public Health Services Grant Application Do not exceed character length restrictions indicated.

LEAVE BLANK—FOR PHS USE ONLY.

Type

Activity

Number

Review Group

Formerly

Council/Board (Month, Year)

Date Received

1. TITLE OF PROJECT (Do not exceed 81 characters, including spaces and punctuation.)      

2. RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS OR PROGRAM ANNOUNCEMENT OR SOLICITATION NO YES (If “Yes,” state number and title)

Number:

     

Title:

     

3. PROGRAM DIRECTOR/PRINCIPAL INVESTIGATOR

3a. NAME (Last, first, middle)

3b. DEGREE(S)

3h. eRA Commons User Name

     

     

     

     

     

3c. POSITION TITLE      

3d. MAILING ADDRESS (Street, city, state, zip code)      

3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT      

3f. MAJOR SUBDIVISION      

3g. TELEPHONE AND FAX (Area code, number and extension)

E-MAIL ADDRESS:

TEL:

     

FAX:

     

     

4. HUMAN SUBJECTS RESEARCH

4a. Research Exempt

If “Yes,” Exemption No.

No Yes

No Yes

     

4b. Federal-Wide Assurance No.

4c. Clinical Trial

4d. NIH-defined Phase III Clinical Trial

     

No Yes

No Yes

5. VERTEBRATE ANIMALS No Yes

5a. Animal Welfare Assurance No.

     

6. DATES OF PROPOSED PERIOD OF SUPPORT (month, day, year—MM/DD/YY)

7. COSTS REQUESTED FOR INITIAL BUDGET PERIOD

8. COSTS REQUESTED FOR PROPOSED PERIOD OF SUPPORT

From

Through

7a. Direct Costs ($)

7b. Total Costs ($)

8a. Direct Costs ($)

8b. Total Costs ($)

     

     

     

     

     

     

9. APPLICANT ORGANIZATION

10. TYPE OF ORGANIZATION

Name

     

Public:  Federal State Local

Address

     

Private:  Private Nonprofit

For-profit:  General Small Business Woman-owned Socially and Economically Disadvantaged

11. ENTITY IDENTIFICATION NUMBER      

DUNS NO.

     

Cong. District

     

12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE

13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION

Name

     

Name

     

Title

     

Title

     

Address

     

Address

     

Tel:

     

FAX:

     

Tel:

     

FAX:

     

E-Mail:

     

E-Mail:

     

14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with Public Health Services terms and conditions if a grant is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

SIGNATURE OF OFFICIAL NAMED IN 13. (In ink. “Per” signature not acceptable.)

DATE      

PHS 398 (Rev. xx/09) Face Page Form Page 1