UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER
AT FORT
WORTH
Office of Grant & Contract Management
EXTERNAL
PROPOSAL TRANSMITTAL FORM
Deadline Date:_______________________
[ ] New [ ] Renewal [ ] Continuation of_____________
Revision of ______________UNTHSC Proposal #:_____________
Type of Project: [ ] Contract [ ] Grant [ ] Other_____________________
PI:________________________ Dept. or Institute:________________________ Phone:____________
Proposal Title:_________________________________________________________________________
____________________________________________________________________________________
Sponsor/Agency:______________________________________________________________________
Start Date:_______________________________ End
Date:___________________________________
Funding: Requested from Agency (Direct Costs): _____________________________
Indirect Costs allowed by Sponsor (______% of ______): _____________________________
TOTAL: _____________________________
Does Project Involve:
[ ] Additional Space/Alterations/Renovations
[ ]
Biological Safety/Recombinant DNA
[ ]
Faculty Salary (if no, attach additional page and explain reason
why)
[ ]
Human Subjects Date Approved: __________________
[ ]
Laboratory Animals Date Approved: __________________
[ ]
Cost Sharing ____Required ____ Voluntary
[ ]
Patent or Copyright
[ ]
Radioisotope/Radiation Sources
[ ]
Subcontract with another institution or Off-Campus Collaboration
[ ] Subcontractor
to any outside institution
[ ]
Other - Attach explanation
Key Words: This project
should be indexed under the following topics, limit maximum of three
(3).
(Examples: aging, vision,
cardiovascular, diabetes, etc.)
1)__________________________
2)__________________________ 3)__________________________
Completed
UNTHSC Form 95-006B (Statement of Significant Financial Interest- Pink
Sheet)
Must Be Attached
If more than one department is participating in the research, fill
out the Request for Split of Indirect Costs
I accept responsibility
for financial oversight for this project as well as compliance with
relevant Health Science Center and sponsor conditions of award
_________________________________ ________
Principal Investigator Date
APPROVALS:
1.________________________________ 2. ______________________________ __________
Department Chair Date OGCM
Signature Date
OR
_________________________________
_______
Institute Director Date
