|
DARTMOUTH COLLEGE/DARTMOUTH HITCHCOCK MEDICAL CENTER
download copy
of instructions (pdf)
Introduction
This routing form must be completed for all proposals submitted to external
funding entities. The form is used to route proposals for on-campus signatures
and also serves as the data entry form for the Sponsored Research database at
the College. Please note that the information requested may not be applicable
to every proposal. Please call the Office of Sponsored Projects at 646-3007 if
you have any questions.
The Council on Sponsored Activities has determined that all investigators
must file a complete copy of proposals submitted to external funding entities
with the Office of Sponsored Projects. This includes all submissions which
require the signature of an authorized institutional official. Records
maintained by Sponsored Projects are the official records of the College and
are subject to review by auditors and other sponsor officials. This information
is also used to generate monthly and annual reports detailing sponsored
activity at the College, and is essential for the College's long range planning
efforts. Timely submission of these documents will facilitate these
activities.
Two days prior to the sponsor submission deadline, the original signed
routing form, together with required supporting documents, must be delivered to
the Office of Sponsored Projects. Required documents include, but are not
necessarily limited to:
- Sponsor face page
- Abstract
- All budget pages, with justifications
- Check list page (NIH)
- Human subject and animal use approvals, as appropriate
Needed documents may vary depending on the requirements of the sponsor.
Routing forms without the required Institutional signatures may be returned to
the Principal Investigator.
A complete and final copy of the proposal must be delivered to the Office of
Sponsored Projects, HB 6210, within ten (10) working days after the proposal
has been submitted to the sponsor.
General Instructions
These instructions are designed to provide assistance to those completing
any of the three formats of the Proposal Routing Form (PRF). These formats
are:
- The Electronic Proposal Routing Form (ePRF), which is completed using
web forms located at <https://oracle-www.dartmouth.edu/dart/groucho/gc_prf.main_menu>
.
- Two forms for completing and submitting the PRF on paper:
- Word Format: provides drop
down lists, form fill in, and automatic calculation of proposal budget
totals.
- PDF: Identical to the Word
version, but without drop down lists, etc ., and designed to be
completed
The instructions follow the order of information as it appears on the paper
forms. Whichever format is used, however, the information provided should be
identical.
Specific Instructions
Principal Investigator: Provide the name of the Principal
Investigator as it appears on the proposal, including the PI's department and
telephone number. Indicate the level of effort the PI will devote to this
project.
% Effort - 9 or 12 months: For faculty with 9 month
appointments who will devote academic time to this project enter the percentage
of effort this investigator will devote to this project during the academic
year (9 months) AND complete Off-term information. For all investigators with
12 month appointments: complete only this box with the percentage of effort
this investigator will devote to this project. E.g., 1 month/9 months = 11%:
enter 11 and complete Off-term field. 1 month/12months = 8%: enter 8.
% Effort Off-term: For 9 month appointments
only enter the percentage of effort this investigator will
devote to this project during the off-term. E.g., 1 month/3
months = 33%; enter 33.
Co-Investigator: Same information as PI. If more than one,
report on a separate sheet. Enter information as it appears on the
proposal.
Key Personnel: Same information as PI. If more than one,
report on a separate sheet.
Program: If this project is being managed through one of
the programs listed, please indicate here.
Project Title: Full title of the project, up to 250
characters (Note: Titles of NIH projects are limited to 56 characters,
including punctuation and spaces between words). Enter information as it
appears on the proposal.
Sponsor: Full name of the sponsor to which the proposal is
to be submitted. Remember to identify the exact name of the sponsor
(e.g., National Cancer Institute or NCI, rather than National
Institutes of Health or NIH). If sponsor is not frequently used, give full name
rather than acronym.
Deadline Due Date: Date by which the proposal must be
received by the sponsor.
Program Solicitation: Provide the number and title of any
program solicitation, such as a Program Announcement (PA), Program Announcement
reviewed in an institute (PAR), RFA (Request for Application), RFP (Request for
Proposals). If this is a Special Appropriation, indicate the Public Law
reference and the Federal Fiscal Year of the appropriation (e.g., P.L.
108-7, FFY2003).
Purpose: Choose the correct category for this project. Note
that this is a drop down list in the Word version of the form.
Mechanism: Choose the correct category. Again, this is a
drop down in Word.
Type: Same as Purpose & Mechanism, above. Choose the
correct category; this is a drop down in Word.
Account #: If this is a continuation of a 5-account,
indicate the account number here.
Budget: For each project year, enter the start & stop
dates, direct & indirect funds being requested. In Word version, Word will
calculate the total $ requested per year, as well as the overall cost of the
project.
Indirect Cost Rate and Notes: Indicate indirect rate used.
If this is different from that documented in the Dartmouth College
Institutional Profile, provide the rationale for using a different rate.
Sub Recipients: Indicate whether it is anticipated that
this project will involve subrecipients.
Financial Declaration: This section consists of the
statement beginning, 'This budget complies . . . ' This statement needs to be
signed by the Department Financial Officer. As will all signatures on the PRF,
this needs to be an original signature. Stamped signatures are not
acceptable.
Assurances & Requirements: This section collects
information regarding a variety of factors.
Human Subjects: Indicate whether this project will involve
human subjects. If it will, provide the Date CPHS protocol
approval was received, CPHS Study Number, Type Of
Review, and (if exempt) the Exemption Category. If
the project will involve humans and CPHS approval has not yet been received, or
is expired (i.e., more than one year old) indicate "Pending" in the
CPHS study ID field, together with the ID number, if you have one. Enter the
date of the most recent CPHS approval.
Exemption Category: Categories are 1 through 6, see 45
CFR 46, Section 101 (b) (1-6).
- Research conducted in established or commonly accepted educational
settings, involving normal educational practices, such as (i) research on
regular and special education instructional strategies, or (ii) research on the
effectiveness of or the comparison among instructional techniques, curricula,
or classroom management methods.
- Research involving the use of educational tests (cognitive, diagnostic,
aptitude, achievement), survey procedures, interview procedures or observation
of public behavior, unless:
(i) information obtained is recorded in such a manner that human subjects can
be identified, directly or through identifiers linked to the subjects; and (ii)
any disclosure of the human subjects' responses outside the research could
reasonably place the subjects at risk of criminal or civil liability or be
damaging to the subjects' financial standing, employability, or
reputation.
- Research involving the use of educational tests (cognitive, diagnostic,
aptitude, achievement), survey procedures, interview procedures, or observation
of public behavior that is not exempt under paragraph (b)(2) of this section,
if:
(i) the human subjects are elected or appointed public officials or candidates
for public office; or (ii) Federal statute(s) require(s) without exception that
the confidentiality of the personally identifiable information will be
maintained throughout the research and thereafter.
- Research involving the collection or study of existing data, documents,
records, pathological specimens, or diagnostic specimens, if these sources are
publicly available or if the information is recorded by the investigator in
such a manner that subjects cannot be identified, directly or through
identifiers linked to the subjects.
- Research and demonstration projects which are conducted by or subject to
the approval of Department or Agency heads, and which are designed to study,
evaluate, or otherwise examine:
(i) Public benefit or service programs; (ii) procedures for obtaining benefits
or services under those programs; (iii) possible changes in or alternatives to
those programs or procedures; or (iv) possible changes in methods or levels of
payment for benefits or services under those programs.
- Taste and food quality evaluation and consumer acceptance studies, (i) if wholesome foods without additives are consumed or (ii) if
a food is consumed that contains a food ingredient at or below the level and
for a use found to be safe, or agricultural chemical or environmental
contaminant at or below the level found to be safe, by the Food and Drug
Administration or approved by the Environmental Protection Agency or the Food
Safety and Inspection Service of the U.S. Department of
Agriculture.
Will HIPAA protected health information be used in this
project? Click here for a
discussion of HIPAA and its applicability to a variety of situations.
- Protected Health Information (PHI) is defined as:
Any information, created or received by us in any form, that IDENTIFIES an
individual and is related to the past, present or future:
- 1. Physical or mental health of the individual,
- 2. Provision of health care to the individual, or
- 3. Payment for health care provided to the individual
Animals: Indicate if animals will be used. If so, indicate
further the date IACUC approval was obtained, the species and quantity of
animals being used, and the IACUC project number. If IACUC approval has expired
or not yet been received, indicate "Pending" in the IACUC Project Number
field.
Environmental Health and Safety: Work involving the
following requires institutional approval and oversight. If applicable
to your proposed or on-going work, failure to complete this section or to
withhold information may be construed as misconduct. Contact EHS if you have
any questions or need assistance (646-1762). Indicate whether any of the
following is applicable.
Radiation: Ionizing radiation; non-ionizing radiation
(lasers, specifically), (UV light used in molecular biology is excepted).
Class IIIb or IV Lasers
Human blood, body fluids or unfixed tissues
Human Pathogens: A link to the American Biological
Safety Association "Risk Group Classification for Infectious Agents"
website is provided for further information.
Recombinant DNA Recombinant DNA research falls under the
oversight of the Institutional Biosafety
Committee (IBC). By checking "Yes" you confirm that your research involves
Recombinant DNA, whether it is exempt from IBC review or not.
Select Agents: A link to the CDC "Select
Agent Program" website is provided for further information.
Other hazardous chemicals: A link to the Dartmouth
EHS "Material Safety Data Sheets" website is provided for further
information. You are asked here to specifically indicate whether materials in
the following groups are being used:
- Chemicals classified as "extremely toxic" or "super toxic", with as
LD50 < 5mg/kg by any route of entry. Consult current MSDS or
toxicology literature for LD50 data. Some examples include
colchicine, strychnine, cyanides, diisopropylfluorophosphate and cyanogen
bromide.
- Extremely toxic or corrosive compressed gases with an LC50 <
5000 ppm or classified by Department of Transportation as inhalation
hazard.
- Explosive, temperature or shock sensitive material.
- Other unstable materials that may undergo chemical or physical changes
during use or extreme processes involving high heat, pressure, vacuum or
temperature. (Processes or chemicals that could generate byproducts or
conditions that can overcome standard control measures or penetrate protective
equipment to cause severe acute or lethal injuries.)
- Carcinogenic chemicals listed or defined by the National Toxicity Program
in the Report on Carcinogens or the International Agency for Research on
Cancer
- Mutagenic or teratogenic chemicals either known or suspected
Cost Sharing: Indicate the amounts needed, by category
(salary & benefits, indirect costs, other). Indicate the source account for
these funds. This section must be signed by the appropriate Dean or
designee.
Cost Sharing Account: Identify the account # from which
cost sharing funds will be drawn.
Matching Funds: Indicate matching funds to be applied to
this project. Development Officer must sign this section.
Certifications: PIs indicate here that they have
Invention Agreement on file, that they are not
debarred or suspended from federal funding, that they are not
delinquent on any federal debt, and that they and their
co-investigators and key personnel have filed conflict of interest
(COI) forms and have reviewed relevant Dartmouth policy.
Principal Investigator must sign this section. Again, original signatures only
- no stamps!
Export Control Information
The answers to the four questions are meant to alert OSP staff of the potential
application of export control regulations to your proposal. Answering “yes” to
any of the four questions will never delay proposal submission. OSP staff may,
however, request further information from the investigator, but will generally
do so after the grant application is completed and submitted. The questions are
meant to be broadly interpreted. When in doubt always answer “yes”.
- Has the topic of export controls come up in any form in connection with
this proposal? Answering “yes” simply means that the topic of export controls
came up in the program announcement, in meetings with sponsor, discussions with
co-investigators, or in some other venue where the grant opportunity was
discussed.
- Will the project include collaboration with a foreign organization? Answer
“yes” if you are including a foreign subcontractor or subrecipient in the
proposal or if you expect to involve a foreign organization in some way in your
project.
- Will the project involve the shipment of equipment or software outside of
the United States? If it is possible you may ship or transmit electronically
software abroad, answer “yes”.
- Will the project require the use of another party’s proprietary information
or materials? Answer “yes” if the project may receive information under a
non-disclosure agreement from the sponsor or from a third party such as project
partner, or consultant.
Personnel/Space Requirements
- Additional Personnel: Will this proposal require
additional personnel, beyond those already employed in the department? If so,
how many, in FTE format?
- Additional Space: Will this proposal require additional
space (office, laboratory, or other) beyond that currently available to the
department? If so, how many square feet (estimated)?
- Space Renovation: Will office, laboratory, or other space
to be used for this project require renovation? If so, will this be of Low,
Medium, or High cost; with Low being under $50,000, Medium between $50,000 and
$150,000, and High over $150,000?
- DC/DHMC Office Space: Will this proposal require the use
of existing DC/DHMC office space? If so, what building and room? On the Word
and ePRF versions of the form, select the building from the list provided. If
the building is not on the list, select "Other" and indicate the building in
the space provided. DC/DHMC space is defined as space owned, rented, or leased
by Dartmouth College or Dartmouth/Hitchcock Medical Center.
- DC/DHMC Research Lab Facilities: Will this proposal
require the use of existing DC/DHMC research laboratory space? As above, for
office space, indicate the building and room.
- Clinical Lab Facilities: Will this proposal require the
use of existing DC/DHMC clinical laboratory space? As above, for office space,
indicate the building and room.
- In-Patient Facilities: Will this proposal require the use
of existing DC/DHMC in-patient facilities (e.g., patient rooms,
operating room)?
- Out-Patient Facilities: Will the proposal require the use
of existing DC/DHMC out-patient facilities (e.g., clinic space,
examining or procedure rooms)?
- Non-DC/DHMC Facilities: Will work for this proposal take
place in Non-DC/DHMC facilities (e.g., other clinics, hospitals,
laboratories)? If so, specify where in the space provided (e.g.,
geographic location, address, name of institution).
- Work at a Foreign Site: Will work take place outside the
political boundaries of the USA? If so, this should have been identified
in the space above, when identifying the location of Non-DC/DHMC
facilities.
Required Signatures: Note that the signature of the
Clinical Research DHMC Financial Administrator has been added to the list of
required signatures. This requirement is added for all clinical research. As
noted above, only original signatures are acceptable. No signature stamps may
be used on the Proposal Routing Form. By signing the routing form,
principal investigators agree to comply with certification statement appearing
above the PI signature line.
Department chairs for all personnel listed on a grant application with 5% or
greater effort, must sign the Proposal Routing Form.
|
