PHS 398 (Rev. 01/18), OMB No. 0925 0001 Forms

User Manual: 398

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Form Approved Through 03/31/2020 OMB No. 0925-0001
Department of Health and Human Services
Public Health Services
Grant Application
Do not exceed character length restrictions indicated.
LEAVE BLANK—FOR PHS USE ONLY.
Type
Activity
Number
Review Group
Formerly
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
NO YES
(If “Yes,” state number and title)
Title:
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) E-MAIL ADDRESS:
TEL:
FAX:
4. HUMAN SUBJECTS RESEARCH
4a. Research Exempt
If “Yes,” Exemption No.
No Yes No Yes
4b. Federal-Wide Assurance No.
4c. Clinical Trial
4d. NIH-defined Phase III Clinical Trial
No Yes
No Yes
5. VERTEBRATE ANIMALS No Yes 5a. Animal Welfare Assurance No.
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
Through
7a. Direct Costs ($)
7b. Total Costs ($)
8a. Direct Costs ($)
8b. Total Costs ($)
9. APPLICANT ORGANIZATION
10. TYPE OF ORGANIZATION
Name
Public:
→
Federal State Local
Address
Private:
→
Private Nonprofit
For-profit:
→
General Small Business
Woman-owned Socially and Economically Disadvantaged
11. ENTITY IDENTIFICATION NUMBER
DUNS NO.
Cong. District
12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE
13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name
Name
Title
Title
Address
Address
Tel: FAX: Tel: FAX:
E-Mail: E-Mail:
14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that
the statements herein are true, complete and accurate to the best of my knowledge, and
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.
SIGNATURE OF OFFICIAL NAMED IN 13.
(In ink. “Per” signature not acceptable.)
DATE
PHS 398 (Rev. 01/18) 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)
E-MAIL ADDRESS:
TEL: 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)
E-MAIL ADDRESS:
TEL: 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)
E-MAIL ADDRESS:
TEL: 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)
E-MAIL ADDRESS:
TEL: FAX:
PHS 398 (Rev. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Face Page-continued Form Page 1-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:
County:
State:
Province:
Country:
Zip/Postal Code:
Project/Performance Site Congressional Districts:
Additional Project/Performance Site Location
Organizational Name:
DUNS:
Street 1:
Street 2:
City:
County:
State:
Province:
Country:
Zip/Postal Code:
Project/Performance Site Congressional Districts:
PHS 398 (Rev. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page 2 Form 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 Organization Role on Project
OTHER SIGNIFICANT CONTRIBUTORS
Name
Organization
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. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page 3 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):
The name of the program director/principal investigator must be provided at the top of each printed page and each continuation page.
RESEARCH GRANT
TABLE OF CONTENTS
Page Numbers
Face Page ..................................................................................................................................................
1
Description, Project/Performance Sites, Senior/Key Personnel, Other Significant Contributors,
and Human Embryonic Stem Cells .........................................................................................................
2
Table of Contents .....................................................................................................................................
Detailed Budget for Initial Budget Period ..............................................................................................
Budget for Entire Proposed Period of Support .............................................................................................
Budgets Pertaining to Consortium/Contractual Arrangements ..........................................................
Biographical Sketch – Program Director/Principal Investigator (Not to exceed five pages each) ...........
Other Biographical Sketches (Not to exceed five pages each – See instructions) ................................
Resources .................................................................................................................................................
Checklist ....................................................................................................................................................
Research Plan ...........................................................................................................................................
1. Introduction to Resubmission Application, if applicable, or Introduction to Revision Application,
if applicable * .......................................................................................................................................
2. Specific Aims * ....................................................................................................................................
3. Research Strategy * ............................................................................................................................
4. Bibliography and References Cited/Progress Report Publication List .................................................
5. Vertebrate Animals ...............................................................................................................................
6. Select Agent Research.........................................................................................................................
7. Multiple PD/PI Leadership Plan ...........................................................................................................
8. Consortium/Contractual Arrangements ................................................................................................
9. Letters of Support (e.g., Consultants) ..................................................................................................
10. Resource Sharing Plan(s) ....................................................................................................................
11. Authentication of Key Biological and/or Chemical Resources .............................................................
12. PHS Human Subjects and Clinical Trials Information ..........................................................................
Appendix (Two identical CDs.)
Check if
Appendix is
Included
* Follow the page limits for these sections indicated in the application instructions, unless the Funding Opportunity Announcement
specifies otherwise.
PHS 398 (Rev. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page Form Page 3
List PERSONNEL (Applicant organization only)
Use Cal, Acad, or Summer to Enter Months Devoted to Project
Enter Dollar Amounts Requested (omit cents) for Salary Requested and Fringe Benefits
NAME
ROLE ON
PROJECT
Cal.
Mnths
Acad.
Mnths
Summer
Mnths
INST.BASE
SALARY
SALARY
REQUESTED
FRINGE
BENEFITS
TOTAL
PD/PI
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
INPATIENT CARE COSTS
OUTPATIENT CARE COSTS
ALTERATIONS AND RENOVATIONS (Itemize by category)
OTHER EXPENSES (Itemize by category)
CONSORTIUM/CONTRACTUAL COSTS DIRECT COSTS
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page)
$
CONSORTIUM/CONTRACTUAL COSTS FACILITIES AND ADMINISTRATIVE COSTS
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
$
PHS 398 (Rev. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page Form Page 4
Program Director/Principal Investigator (Last, First, Middle):
DETAILED BUDGET FOR INITIAL BUDGET PERIOD
DIRECT COSTS ONLY
FROM THROUGH
0
0
0
0
0
0
0
0
0
0
0
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
YEAR OF SUPPORT
REQUESTED
4th ADDITIONAL
YEAR OF
SUPPORT
REQUESTED
5th ADDITIONAL
YEAR OF SUPPORT
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. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page Form Page 5
0
0
0
0
0
0
0
0
0
0
0
Program Director/Principal Investigator (Last, First, Middle):
RESOURCES
Follow the 398 application instructions in Part I, 4.7 Resources.
PHS 398 (Rev. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page Resources Format Page
Program Director/Principal Investigator (Last, First, Middle):
CHECKLIST
TYPE OF APPLICATION
(Check all that apply.)
NEW application. (This application is being submitted to the PHS for the first time.)
RESUBMISSION of application number:
(This application replaces a prior unfunded version of a new, renewal, or revision application.)
RENEWAL of grant number:
(This application is to extend a funded grant beyond its current project period.)
REVISION to grant number:
(This application is for additional funds to supplement a currently funded grant.)
CHANGE of program director/principal investigator.
Name of former program director/principal investigator:
CHANGE of Grantee Institution. Name of former institution:
FOREIGN application Domestic Grant with foreign involvement
List Country(ies)
Involved:
INVENTIONS AND PATENTS (Renewal appl. only) No Yes
If “Yes,” Previously reported Not previously reported
1. PROGRAM INCOME (See instructions.)
All applications must indicate whether program income is anticipated during the period(s) for which grant support is request. If program income is
anticipated, use the format below to reflect the amount and source(s).
Budget Period
Anticipated Amount
Source(s)
2. ASSURANCES/CERTIFICATIONS (See instructions.)
In signing the application Face Page, the authorized organizational representative agrees to comply with the policies, assurances and/or certifications
listed in the application instructions when applicable. Descriptions of individual assurances/certifications are provided in the NIH Grants Policy
Statement, Section 4: Public Policy Requirements, Objectives and Other Appropriation Mandates. If unable to certify compliance, where applicable,
provide an explanation and place it after this page.
3. FACILITIES AND ADMINSTRATIVE COSTS (F&A)/ INDIRECT COSTS. See specific instructions.
HHS Agreement dated:
No Facilities And Administrative Costs Requested.
HHS Agreement being negotiated with
Regional Office.
No HHS Agreement, but rate established with
Date
CALCULATION* (The entire grant application, including the Checklist, will be reproduced and provided to peer reviewers as confidential information.)
a. Initial budget period:
Amount of base $
x Rate applied
% = F&A costs $
b. 02 year
Amount of base $
x Rate applied
% = F&A costs $
c. 03 year
Amount of base $
x Rate applied
% = F&A costs $
d. 04 year
Amount of base $
x Rate applied
% = F&A costs $
e. 05 year
Amount of base $
x Rate applied
% = F&A costs $
TOTAL F&A Costs $
*Check appropriate box(es):
Salary and wages base
Modified total direct cost base
Other base (Explain)
Off-site, other special rate, or more than one rate involved (Explain)
Explanation (Attach separate sheet, if necessary.):
PHS 398 (Rev. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page Checklist Form Page
Enter Rate above as a decimal (e.g., 0.25 for 25%, 0.495 for 49.5%)
0.00%
0.00
0.00%
0.00
0.00%
0.00
0.00%
0.00
0.00%
0.00
0.00
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. 01/18) Page PHS Human Subjects and Clinical Trial Information
DO NOT SUBMIT UNLESS REQUESTED
Renewal Applications Only
ALL PERSONNEL REPORT
Always list the PD/PI(s). In addition, list all other personnel who participated in the project during the current
budget period for at least one person month or more, regardless of the source of compensation (a person month
equals approximately 160 hours or 8.3% of annualized effort). Use Cal, Acad, or Summer to Enter Months
Devoted to Project.
Commons ID
Name
Degree(s)
SSN
(last 4
digits)
Role on Project
(e.g. PD/PI, Res. Assoc.)
DoB
(MM /YY)
Cal
Acad
Summer
PHS 398 (Rev. 01/18 Approved Through 03/31/2020) OMB No. 0925-0001
Page All Personnel Report Format Page
Mailing address for application
Use this label or a facsimile
All applications and other deliveries to the Center for Scientific Review must come either via
courier delivery or via the United States Postal Service (USPS.) Applications delivered by
individuals to the Center for Scientific Review will not be accepted.
Applications sent via the USPS EXPRESS or REGULAR MAIL should be sent to the following address:
CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE
ROOM 1040 – MSC 7710
BETHESDA, MD 20892-7710
NOTE: All applications sent via a courier delivery service (non-USPS) should use this address, but
CHANGE THE ZIP CODE TO 20817
The telephone number is 301-435-0715. C.O.D. applications will not be accepted.
A special label for responding to RFAs is not required.

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