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    Grants and Contracts Subrecipient Certification

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    Subrecipient Certification: Project Specific

    Information asked for:

    • CPMCRI's Proposal Entitled:

    • Subk No.:

    • Prime Sponsor:

    • Grant No (If Applicable:)

    • Total Funds Requested:

    • Performance Period:
      Begin & End:


    Section A - Institution Contacts
    Provide the following information for CPMCRI's PI & Subrecipient's PI:
    • Name

    • Address:

    • Phone:

    • Fax:

    • Email:


    Administrative Contact
    Provide following for CPMC and Subk Contacts
    • Name:

    • Address:

    • Phone:

    • Fax:

    • Email:


    Section B - Certifications Specific To Proposal/Agreement

    1. Facilities & Administration Rates Included In This Proposal Have Been Calculated Based On: (check one)

      • Our Federally-Negotiated F&A Rates For This Type Of Work, Or A Reduced F&A Rate That We Hereby Agree To Accept.
        Please Attach A Copy Of Your F&A Rate Agreement Via Hard Copy, Website, Or Email Before A Subaward Will Be Issued.

      • Other Rates (Please Specify The Basis On Which The Rate Has Been Calculated In Separate Attachment)

      • Not Applicable (Please Specify Why):

    2. Fringe Benefit Rates Included In This Proposal:

      • Are Consistent With Or Lower Than Our Federally-Negotiated Rate Agreement.

      • Are Based On Other Rates (Please Specify The Basis On Which The Rate Has Been Calculated In Section D Comments Below.

    3. Human Subjects

      • Yes

        • If "Yes," Copies Of The IRB Approval And Approved "Informed Consent" Form Are Attached.

        • If "Yes," Copies Of IRB Approval and "Informed Consent" Will Be Forwarded To CPMCRI C&G Office As Soon As They Become Available.

      • No

      • Exempt

      • Fwa #

    4. Human Research Participants Protection Training

    5. # Of Applicable Personnel:
      • Certification Of Education On The Protection Of Human Research Participants For All Individuals Identified As Senior/Key Personnel Attached.

      • Certification Will Be Provided At Time Of Award.

    6. Animal Subjects
    7. Iacuc Assurance #
      • Yes

        • If "Yes," Copy Of The IACUCApproval Is Attached.

        • If "Yes," Copy Of IACUC Will Be Forwarded To CPMCRI C&G Office As Soon As They Become Available, But No Later Than Time Of Award.

      • No

    8. Biosafety Committee

      • Yes

        • If Yes: A Copy Of The Biosafety Committee Approval Form Is Attached.

        • If Yes: Copy Of Biosafety Committee Approval Will Be Forwarded To CPMCRI C&G Office As Soon As It Becomes Available.

      • No

    9. Conflict Of Interest (Applicable PHS, NIH, NSF, DHHS Or Any Other Program Requiring Federal Financial Disclosure).

      • Subrecipient Organization/Institution hereby certifies that it has an active and enforced conflict of interest policy that is consistent with the provision of 42 CFR part 50, subpart f "responsibility of applicants for promoting objectivity in research." subrecipient also certifies that, to the best of insitution's knowledge, 1) all financial disclosures have been made related to the activities that may be funded by or through a resulting agreement, and required by its conflict of interest policy; and 2) all identified conflicts of interest have or will have been satisfactorily managed, reduced or eliminated in accordance with subrecipient's conflict of interest policy prior to the expenditures of any funds under resultant agreement.

      • Not Applicable Because Project Is Not Being Funded By PHS, NIH, NSF, OR DHHS

    10. Cost Sharing/Matching

      • Yes

      • No

      • In-Kind

        • Yes

        • No

      (Cost Sharing, Matching and Or In-Kind Amounts and Justification Should Be Included In The Subrecipient's Budget). If Yes, Please Describe Below What Sources of Funds Will be Used To Cover The Costs And How It Will Be Tracked.
    11. Certification Regarding Debarment & Suspension

      • Yes

      • No

    Subrecipient certifies that neither it nor the principals are presently debarred and suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in any federal department or agency. Subawards to any entity or individual included in the federal excluded parties are prohibited.

    Section C: Add Comments if any:

    Section D - Subrecipient Institutional Approval
    The information, certifications and representations above have been read, signed, and made by an authorized official of the subrecipient named herein. The appropriate programmatic and administrative personnel involved in this application are aware of agency policy in regard to subawards and are prepared to establish the necessary inter-institutional agreements consistent with those policies.

    Provide Signature/Date Of Subrecipient's Authorized Official

    Authorized Official Information
    • Address:

    • Phone:

    • Email:



    Last Revision Date: 11/06/08



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