Phs 398, Fp1 (rev. 11/07), Face Page, Form Page 1

Form Approved Through 6/30/2012 OMB No. 0925-0001
LEAVE BLANK—FOR PHS USE ONLY.
Department of Health and Human Services
Public Health Services
Type Activity Number
Grant Application
Review Group
Formerly
Do not exceed character length restrictions indicated.
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
7. COSTS REQUESTED FOR INITIAL
8. COSTS REQUESTED FOR PROPOSED
SUPPORT
(month, day, year—MM/DD/YY)
BUDGET
PERIOD
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
SIGNATURE OF OFFICIAL NAMED IN 13.
DATE
the statements herein are true, complete and accurate to the best of my knowledge, and
(In ink. “Per” signature not acceptable.)
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.
PHS 398 (Rev. 6/09)
Face Page Form Page 1