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Form Approved Through 02/28/2023
OMB No. 0925-0001
LEAVE BLANK—FOR PHS USE ONLY.
Type
Activity
Number
Review Group
Formerly
Department of Health and Human Services
Public Health Services
Grant Application
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
(If “Yes,” state number and title)
Number:
Title:
NO
YES
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)
TEL:
E-MAIL ADDRESS:
FAX:
4. HUMAN SUBJECTS RESEARCH
No
4a. Research Exempt
Yes
No
4b. Federal-Wide Assurance No.
Yes
4c. Clinical Trial
No
5. VERTEBRATE ANIMALS
If “Yes,” Exemption No.
No
4d. NIH-defined Phase III Clinical Trial
Yes
No
Yes
5a. Animal Welfare Assurance No.
Yes
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
7a. Direct Costs ($)
8a. Direct Costs ($)
Through
9. APPLICANT ORGANIZATION
Name
7b. Total Costs ($)
8b. Total Costs ($)
10. TYPE OF ORGANIZATION
Address
Public:
→
Federal
Private:
→
Private Nonprofit
For-profit: →
Woman-owned
General
State
Local
Small Business
Socially and Economically Disadvantaged
11. ENTITY IDENTIFICATION NUMBER
DUNS NO.
Cong. District
12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE
Name
13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name
Title
Title
Address
Address
Tel:
E-Mail:
FAX:
Tel:
FAX:
E-Mail:
SIGNATURE OF OFFICIAL NAMED IN 13.
14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that
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.
DATE
PHS 398 (Rev. 03/2020)
Face Page
Form Page 1
Use only if preparing an application with Multiple PDs/PIs. See http://grants.nih.gov/grants/multi_pi/index.htm for details.
Contact Program Director/Principal Investigator (Last, First, Middle):
3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3h. NIH 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)
TEL:
E-MAIL ADDRESS:
FAX:
3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3h. NIH 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)
TEL:
E-MAIL ADDRESS:
FAX:
3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
3h. NIH 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)
TEL:
E-MAIL ADDRESS:
FAX:
3. PROGRAM DIRECTOR / PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. DEGREE(S)
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)
TEL:
FAX:
E-MAIL ADDRESS:
3h. NIH Commons User Name
PHS 398 (Rev. 03/2020 Approved Through 02/28/2023)
OMB No. 0925-0001
Form Page 1-continued
Face Page-continued
Program Director/Principal Investigator (Last, First, Middle):
PROJECT SUMMARY (See instructions):
RELEVANCE (See instructions):
PROJECT/PERFORMANCE SITE(S) (if additional space is needed, use Project/Performance Site Format Page)
Project/Performance Site Primary Location
Organizational Name:
DUNS:
Street 1:
Street 2:
City:
Province:
County:
State:
Country:
Zip/Postal Code:
Project/Performance Site Congressional Districts:
Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:
Street 2:
City:
Province:
County:
Country:
Project/Performance Site Congressional Districts:
State:
Zip/Postal Code:
PHS 398 (Rev. 03/2020 Approved Through 02/28/2023)
OMB No. 0925-0001
Form Page 2
Page 2
Program Director/Principal Investigator (Last, First, Middle):
SENIOR/KEY PERSONNEL. See instructions. Use continuation pages as needed to provide the required information in the format shown below.
Start with Program Director(s)/Principal Investigator(s). List all other senior/key personnel in alphabetical order, last name first.
Name
eRA Commons User Name
OTHER SIGNIFICANT CONTRIBUTORS
Name
Organization
Organization
Role on Project
Role on Project
Human Embryonic Stem Cells
No
Yes
If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list:
https://grants.nih.gov/stem_cells/registry/current.htm. Use continuation pages as needed.
If a specific line cannot be referenced at this time, include a statement that one from the Registry will be used.
Cell Line
PHS 398 (Rev. 03/2020 Approved Through 02/28/2023)
Page 3
OMB No. 0925-0001
Form Page 2-continued
Number the following pages consecutively throughout
the application. Do not use suffixes such as 4a, 4b.
Program Director/Principal Investigator (Last, First, Middle):
.
PHS 398 (Rev. 03/2020 Approved Through 02/28/2023)
OMB No. 0925-0001
Form Page 3
Page
Program Director/Principal Investigator (Last, First, Middle):
BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD
DIRECT COSTS ONLY
BUDGET CATEGORY
TOTALS
INITIAL BUDGET
PERIOD
(from Form Page 4)
2nd ADDITIONAL
YEAR OF SUPPORT
REQUESTED
3rd ADDITIONAL
4th ADDITIONAL
5th ADDITIONAL
YEAR OF SUPPORT YEAR OF SUPPORT YEAR OF SUPPORT
REQUESTED
REQUESTED
REQUESTED
PERSONNEL: Salary and fringe
benefits. Applicant organization
only.
CONSULTANT COSTS
EQUIPMENT
SUPPLIES
TRAVEL
INPATIENT CARE
COSTS
OUTPATIENT CARE
COSTS
ALTERATIONS AND
RENOVATIONS
OTHER EXPENSES
DIRECT CONSORTIUM/
CONTRACTUAL
COSTS
SUBTOTAL DIRECT COSTS
(Sum = Item 8a, Face Page)
F&A CONSORTIUM/
CONTRACTUAL
COSTS
TOTAL DIRECT COSTS
TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD
$
JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.
PHS 398 (Rev. 03/2020 Approved Through 02/28/2023)
Page
Program Director/Principal Investigator (Last, First, Middle):
RESOURCES
Follow the 398 application instructions in Part I, 4.7 Resources.
OMB No. 0925-0001
Form Page 5
PHS Human Subjects and Clinical Trials Information
Note: The PHS Human Subjects and Clinical Trials Information form is not included in this combined form. See
individual form here: https://grants.nih.gov/grants/forms/human-subjects-clinical-trials-information.pdf.
** The PHS Human Subjects and Clinical Trials Information fillable form can be opened in Internet Explorer.
However, you may download it from any browser.**
0925-0001 (Rev. 03/2020)
Page
PHS Human Subjects and Clinical Trial Information
Grant Proposal
[WLO: 3] [CLO: 6]
Prior to beginning work on this assignment,
Read
•
Steps 1, 3, and 4 of Winning Grants Step by Step: The Complete Workbook for
Planning, Developing, and Writing Successful ProposalsLinks to an external site.
It is also recommended you review the following resources listed on the recommended
resources page:
•
•
•
What Is Biomedical and Health Informatics?Links to an external site.
Data Analytics and Informatics Are Two Separate Disciplines (and Why This Matters
to HIM)Links to an external site.
Biomedical Informatics vs Healthcare Informatics: A Side-By-Side ComparisonLinks
to an external site.
Grant proposal writing is an essential process if you need the funding for your research
project, educational program, quality improvement initiative, or others. However, it can
be intimidating for the novice. Yet if you follow the step-by-step process described in
the required text by O’Neal-McElrath (2019), you can create a proposal with little
anxiety.
For this assignment, you will have an opportunity to complete a basic grant writing
proposal using the information you provided in your Week 6 Grant Writing Exercise
discussion forum.
Instructions
For your assignment,
•
Complete the Grant Application Template Download Grant Application
Template.
o You can be creative in the information you input into the
application except in the following sections: Project Summary,
Relevance, and Justification.
▪ These sections will be described in your paper.
o For examples of what a grant application can look like, review the
following:
▪ Grant Application Example 1Download Grant Application
Example 1
▪
Grant Application Example 2Download Grant Application
Example 2
In a separate paper,
•
•
•
•
Summarize the grant request and reasons for the request of the grant.
List the goals and objectives for the use of the grant.
Explain the significance of the problem identified.
Identify the stakeholders who would be affected by the project.
Save both documents and submit them to Waypoint. You can submit both documents.
The Grant Proposal assignment
•
•
•
•
•
Must be formatted according to APA StyleLinks to an external site. as outlined
in the Writing Center’s APA Formatting for Microsoft WordLinks to an external
site.
Must include a separate title page with the following:
o Title of paper in bold font
▪ There should be a space between the title and the rest of
the information on the title page.
o Student’s name
o Name of institution (University of Arizona Global Campus)
o Course name and number
o Instructor’s name
o Due date
Must utilize academic voice. See the Academic VoiceLinks to an external
site. resource for additional guidance.
Must include an introduction and conclusion paragraph. Your introduction
paragraph needs to end with a clear thesis statement that indicates the
purpose of your paper.
o For assistance on writing Introductions & ConclusionsLinks to an
external site. as well as Writing a Thesis StatementLinks to an external
site., refer to the Writing Center resources.
Must use at least two peer-reviewed sources in addition to the course text.
o The Scholarly, Peer-Reviewed, and Other Credible SourcesLinks to an
external site. table offers additional guidance on appropriate source
types. If you have questions about whether a specific source is
appropriate for this assignment, please contact your instructor.
Your instructor has the final say about the appropriateness of a
specific source for a particular assignment.
o To assist you in completing the research required for this
assignment, view this UAGC Library Quick ‘n’ DirtyLinks to an
•
•
external site. tutorial, which introduces the UAGC Library and the
research process, and provides some library search tips.
Must document any information used from sources in APA Style as outlined in
the Writing Center’s APA: Citing Within Your PaperLinks to an external site.
Must include a separate references page that is formatted according to APA
Style as outlined in the Writing Center. See the APA: Formatting Your References
ListLinks to an external site. resource in the Writing Center for specifications.
Carefully review the Grading RubricLinks to an external site. for the criteria that will be
used to evaluate your assignment.
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