Petit Institute Core Facilities
Sponsored Programs/Research Proposal Authorization
Contact Information
First Name
Last Name
Email
Phone
School/Department/Company
Sponsored Programs/Research Proposal Authorization
Sponsoring Organization Name (Funding Organization or the Organization the SubAward is From)
Response Required
Mailing Address of Sponsoring Organization
Response Required
Is there a Sponsoring Government Organization? (if yes, provide the name)
Yes
No
I don't know
Response Required
Prime Contract Number
Response Required
Check Preferred Mailing Method
Electronic (Email or Fax if Applicable)
Express Courier
U.S. Express Mail
First Class Certified
Response Required
Technical Contact Name
Response Required
Technical Contact Phone Number
Response Required
Technical Contact Email
Response Required
Administrative Contact Name
Response Required
Administrative Contact Phone Number
Response Required
Administrative Contact Email
Response Required
Source of Funds, if Different from Sponsoring Organization or Prime:
Response Required
Contract Number for Source of Funds
Response Required
Special Review Checklist: The Proposal Submitted Involves the Following
Human Subject Research? (if yes, provide IRB Protocol Number and Expiration Date)
Yes
No
Response Required
Vertebrate Animals? (if yes, provide IACUC Protocol Number and Expiration Date)
Yes
No
Response Required
Recombinant DNA (if yes, provide IBC Registration Number and Expiration Date)
Yes
No
Response Required
Select Agents (See list at www.cdc.gov/od/sap/docs/salist.pdf)(More info: www.cdc.gov/od/sap/)
Yes
No
Response Required
Biological agents (List all that Apply: Infectious or pathogenic agent(s)/ Human tissues or bodily fluid/ Other biological materials)
Yes
No
Response Required
Physical Agents (List all that apply: Chemicals/ Sharps/ Laser/ Radiation/ Thermal agent)
Yes
No
Response Required
Materials Transfer Agreement (MTA)
Yes
No
Response Required
Professional Education Program (if yes, please route to DLPE)
Yes
No
Response Required
Subaward(s) are proposed
Yes
No
Response Required
Teaming Agreement
Yes
No
Response Required
Research involves export of info or materials to another country
Yes
No
Response Required
Research involves a foreign sponsor or collaborator, or will be performed in whole or in part outside the U.S.
Yes
No
Response Required
Contract anticipated to contain restrictions on publication or the use of Foreign Nationals
Yes
No
Response Required
If answered "Yes" above, please answer the following questions. (Otherwise, skip this section)
Involves the use of pre-existing (background) intellectual property (if yes, specify if Georgia Tech's or a Third Party's; if a Third Party's, write an explanation)
Yes
No
A member of the research team has a Significant Financial Interest (SFI) related to this project. If "yes", you must complete the Proposal Financial Interest in Research Report within eCOI
Yes (https://ecoi.research.gatech.edu)
No
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