Approval to Apply for External Funding

UW-River Falls

This form should be completed for any proposal submitted to a source which may provide funding over and above regular budgetary support.

Title of Proposal:

Principal investigator(s)/project director(s):

Source from which funding is sought:

Proposed beginning date:                                                                       Ending date:

How did you learn of this funding opportunity?:

Please summarize the project requirements in each of the following categories. Write N/A if not applicable.

Space requirements (special or additional):

Released time of principal project personnel:

Payments to other UW-River Falls staff:

Additional institutional financial support or cash match:

Budget number for support or match:

Other institutional support (e.g., in-kind match):

Does this project involve research using animals? If so, have you obtained approval from the Institutional Animal Care and Use Committee?:                      Protocol #:

Does this project involve research using human subjects? If so, have you obtained approval from the Institutional Review Board for the Protection of Human Subjects?:                      Protocol #:

Direct project costs: $

Indirect costs/overhead rate*:

Indirect costs/overhead: $

Total requested: $

Have the project's personnel all completed and submitted signed Financial Disclosure Statements as required by many funding agencies and AP 37?:

                                                           Signatures of Approval                             Date Approved

Principal Investigator/Project Director: ______________________________________________

Co-PI/co-PD(s), other faculty/staff      ______________________________________________

who are involved in the project:           ______________________________________________

Department chair:                               ______________________________________________

Dean:                                                 ______________________________________________

Grants Office:                                     ______________________________________________

Business Office:                                  ______________________________________________

Provost/Vice Chancellor:                    ______________________________________________

Additional information/Comments:

*Note: the UW Board of Regents requires us to ask for the maximum indirect cost rate the funding source will allow, up to our federally negotiated rate--44% of salaries and fringe benefits. If the rate you are requesting is different from that rate, please explain the divergence.

Financial Disclosure Statement for Grant-Funded Research

Each investigator (i.e., each person who is responsible for the design, conduct, or reporting of research as part of the proposed project) must complete a form. (Photocopy this form as necessary)

Consult the reverse side of this form for definitions of financial interest and a formula to follow to determine what must be reported.

Name:                                                                                          Dept:

Title of grant proposal:

_____ I have no significant financial interests to report.

_____ I and/or my immediate family receive or expect to receive payments totaling $5,000 or more per year from a single for-profit business enterprise that would reasonably appear to be directly and significantly affected by my research or educational activities which are funded or may be funded by federal agencies.

Name of Entity                                    Type of Payment (Salary,                                 Amount of Payment                

Making Payments                                Dividend, Royalty, etc.)

___________________                    _______________________                            _______________

___________________                    _______________________                            _______________

___________________                    _______________________                            _______________

_____ I and/or my immediate family have ownership interests of 5% or greater in a single for-profit business enterprise that would reasonably appear to be directly and significantly affected by my research or educational activities which are funded or may be funded by federal agencies.

Name of Entity                                    Type of Payment (Salary,                                    % of Interest                          

Making Payments                                Dividend, Royalty, etc.)

___________________                  _______________________                           _______________

___________________                  _______________________                           _______________

___________________                  _______________________                           _______________

I hereby certify that, to the best of my knowledge, the above information is correct.

Signature: _______________________________________                         Date: ________________

Types of interest that are reportable unless exempt under Section III:

Anything of monetary value that you and/or your immediate family received from for-profit businesses, including but not limited to

• salaries or other payments for services (e.g. consulting fees or honoraria)
• equity interests (e.g. stocks, stock options, or other ownership interests)
• intellectual property rights (e.g. patents, copyrights, and royalties from such rights, including books if published by commercial presses)

Types of interest that are not reportable:

• salaries, royalties, or other payments from UW-River Falls
• income from seminars, lectures, or teaching engagements sponsored by public or nonprofit entities
• payments from advisory committees or review panels for public or nonprofit entities
• payments from a single business if the entire amount of payments you and your immediate family together received is less than $5,000.
• ownership interest in a business if you and your immediate family's ownership interest in the business together represent less than 5% of the total ownership interests in the business.

Formula to determine whether a financial interest is reportable:

Step 1.      Do you and/or your immediate family have a financial interest from or in a for-profit business that is reasonably likely to be directly and significantly affected by the research or educational activities for which you have received or expect within the year to seek and receive funding? If not, then the interest is not reportable. If yes, go to step 2.

Step 2.     Do you and/or your immediate family together receive from such a business $5,000 or more per year, of is the ownership interest you and your family have together in such a business 5% or more of the total ownership interest? If no, then the interest is not reportable. If yes, you must report the interest(s) on the other side of this form.

Last updated: 3/4/99