Fillable Printable Phs 398, Fp1 (Rev. 6/09), Face Page, Form Page 1
Fillable Printable Phs 398, Fp1 (Rev. 6/09), Face Page, Form Page 1
Phs 398, Fp1 (Rev. 6/09), Face Page, Form Page 1
Form Approved Through 6/30/2012 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 n
u
m
ber and title)
Number: 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)
E-MAIL ADDRESS:
3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3f. MAJOR SUBDIVISION
3g. TELEPHONE AND FAX (Area code, number and extension)
TEL: FAX:
4. HUMAN SUBJECTS RESEARCH
No Yes
4a. Research Exempt If “Yes,” Exemption No.
No Yes
4b. Federal-Wide Assurance No. 4c. Clinical Trial
No Yes
4d. NIH-defined Phase III Clinical Trial
No Yes
5. VERTEBRATE ANIMALS No Yes
5a. Animal Welfare Assurance No
6. DATES OF PROPOSED PERIOD OF
SUPPORT
(
month
,
da
y, y
ear—MM/DD/YY
)
From Through
7. COSTS REQUESTED FOR INITIAL
BUDGET PERIOD
8. COSTS REQUESTED FOR PROPOSED
PERIOD OF SUPPORT
7a. Direct Costs ($) 7b. Total Costs ($) 8a. Direct Costs ($) 8b. Total Costs ($)
9. APPLICANT ORGANIZATION
Name
Address
10. TYPE OF ORGANIZATION
Public: → Federal State Local
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
Name
Title
Address
Tel: FAX:
E-Mail:
13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name
Title
Address
Tel: FAX:
E-Mail:
14. APPLICANT O RGANIZATION CERTIFICATION AN D 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. 6/09) Face Page
Form Page 1
