BROOKHAVEN NATIONAL LABORATORY

**TECHNOLOGY MATURATION PROPOSAL INFORMATION QUESTIONNAIRE**

  ------------------------- -- ------- ------- --------- -- ----------- -- -------------
  **PRINCIPAL                                               **PHONE**      
  INVESTIGATOR**                                                           

  **DEPARTMENT/DIVISION**                                   **DATE**       

  **OTHER INVESTIGATORS**                                                  

  **TITLE OF TECHNOLOGY                                                    
  MATURATION PROPOSAL**                                                    

  **PROJECT TERM**             From            Through                     
  (month/year)                                                             
  ------------------------- -- ------- ------- --------- -- ----------- -- -------------

# INSTRUCTIONS

> Under **Brief Description of Project**, provide a summary of the
> proposed project including the motivation for the undertaking and the
> approach that will be used. Also indicate how the project meets the
> purpose of the Technology Maturation Program for activities that
> increase the potential for transfer of the technology. Note any
> commercial interest already expressed.
>
> Under **Expected Results**, clearly enunciate what the expected
> results are. Indicate how these results support commercialization of
> the technology.
>
> **These two sections should be limited in length to the part of the
> first page under the header.**
>
> The ***Technology Development*** section under the **Project
> Description** may include the motivation for the project, the
> fundamental problem to be solved, the approach to be taken and why it
> should work, and what a successful outcome would look like. Include a
> description of the technical development expected. This section is
> limited to three (3) pages. In the ***Project Plan*** section,
> describe the tasks to be completed as well as any deliverables or
> milestones. Include timing, probability of success, and assignment of
> personnel, services, and property. **Milestones should be demonstrable
> at least semiannually; quarterly is preferred**.
>
> On the PIs' CVs, particularly point out experience in industry or with
> commercial partners in CRADAs, WFO, and licensing.
>
> Complete the Questionnaire, obtain the required approvals, and provide
> a budget prepared by your department administrator. Break down the
> funding by fiscal year and by the broad categories of labor, materials
> and supplies, travel (foreign & domestic), services and subcontracts.
> Indicate the intent to use collaborators, postdoctoral research
> associates, and/or students. Identify the various burdens applied,
> i.e., organizational, materials, contracts, and any other charges.
> **The Instructions should be removed before proceeding.**

**SUMMARY OF PROJECT**

**Brief Description of Project**:

**Expected Results**:

**PROJECT DESCRIPTION**

***Technical Development***

What will we have when we are done? Is this all the work anticipated to
be required to enable the technology for commercialization? What are the
technical risks in the proposed project (i.e. that could result in
failure to achieve stated objectives)?

***Project Plan***

Task/stage 1: Name of task *e.g., "Name Project"*

-   *Deliverables*: Project name

-   *Duration of task or task end date*: Three months

-   *Personnel, services, and property required*: principal
    investigators, post-doc 1, copy services, whiteboard

-   *Task-specific risk and probability of success*: Delay in hiring a
    post-doc is the biggest foreseeable impediment to success, but the
    likelihood of succeeding within three months is at least 95%.

Task 2: Name of task

-   *Deliverables*:

-   *Duration of task or task end date*:

-   *Personnel, services, and property required*:

-   *Task-specific risk and probability of success*:

Task 3: Name of task

-   *Deliverables*:

-   *Duration of task or task end date*:

-   *Personnel, services, and property required*:

-   *Task-specific risk and probability of success*:

**VITA** (Principal Investigator)

+-----------------------------+---+-----------------------+---+---+-------+
| **1. [HUMAN                 |   |                       | Y |   |       |
| SUBJECTS]{.underline}**     |   |                       | / |   |       |
| (Reference: DOE Order       |   |                       | N |   |       |
| 1300.3)                     |   |                       |   |   |       |
|                             |   |                       |   |   |       |
| > Are human subjects        |   |                       |   |   |       |
| > involved from BNL or a    |   |                       |   |   |       |
| > collaborating             |   |                       |   |   |       |
| > institution?              |   |                       |   |   |       |
| >                           |   |                       |   |   |       |
| > If **yes**, attach copy   |   |                       |   |   |       |
| > of the current            |   |                       |   |   |       |
| > Institutional Review      |   |                       |   |   |       |
| > Board Approval and        |   |                       |   |   |       |
| > Informed Consent Form     |   |                       |   |   |       |
| > from BNL and/or           |   |                       |   |   |       |
| > collaborating             |   |                       |   |   |       |
| > institution.              |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **2. [VERTEBRATE            |   |                       | Y |   |       |
| ANIMALS]{.underline}**      |   |                       | / |   |       |
|                             |   |                       | N |   |       |
| > Are vertebrate animals    |   |                       |   |   |       |
| > involved?                 |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > If **yes**, has approval  |   |                       | Y |   |       |
| > from BNL's Animal Care    |   |                       | / |   |       |
| > and Use Committee been    |   |                       | N |   |       |
| > obtained?                 |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **3. [NEPA                  |   |                       | Y |   |       |
| REVIEW]{.underline}**       |   |                       | / |   |       |
|                             |   |                       | N |   |       |
| > Are the activities        |   |                       |   |   |       |
| > proposed similar to those |   |                       |   |   |       |
| > now carried out in the    |   |                       |   |   |       |
| > Department/Division which |   |                       |   |   |       |
| > have been previously      |   |                       |   |   |       |
| > reviewed for potential    |   |                       |   |   |       |
| > environmental impacts and |   |                       |   |   |       |
| > compliance with federal,  |   |                       |   |   |       |
| > state, local rules and    |   |                       |   |   |       |
| > regulations, and BNL's    |   |                       |   |   |       |
| > Environment, Safety, and  |   |                       |   |   |       |
| > Health Standards?         |   |                       |   |   |       |
| > (Therefore, if funded,    |   |                       |   |   |       |
| > proposed activities would |   |                       |   |   |       |
| > require no additional     |   |                       |   |   |       |
| > environmental             |   |                       |   |   |       |
| > evaluation.)              |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > If **no**, has a NEPA     |   |                       | Y |   |       |
| > review been completed in  |   |                       | / |   |       |
| > accordance with the       |   |                       | N |   |       |
| > Subject Area National     |   |                       |   |   |       |
| > Environmental Policy Act  |   |                       |   |   |       |
| > (NEPA) and Cultural       |   |                       |   |   |       |
| > Resources Evaluation and  |   |                       |   |   |       |
| > the results documented?   |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > (Note: If a NEPA review   |   |                       |   |   |       |
| > has not been completed,   |   |                       |   |   |       |
| > submit a copy of the work |   |                       |   |   |       |
| > proposal to the BNL NEPA  |   |                       |   |   |       |
| > Coordinator for review.   |   |                       |   |   |       |
| > No work may commence      |   |                       |   |   |       |
| > until the review is       |   |                       |   |   |       |
| > completed and             |   |                       |   |   |       |
| > documented.)              |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **4. [ES&H                  |   |                       | Y |   |       |
| CO                          |   |                       | / |   |       |
| NSIDERATIONS]{.underline}** |   |                       | N |   |       |
|                             |   |                       |   |   |       |
| > Does the proposal provide |   |                       |   |   |       |
| > sufficient funding for    |   |                       |   |   |       |
| > appropriate               |   |                       |   |   |       |
| > decommissioning of the    |   |                       |   |   |       |
| > research space when the   |   |                       |   |   |       |
| > experiment is complete?   |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > Is there an available     |   |                       | Y |   |       |
| > waste disposal path for   |   |                       | / |   |       |
| > project wastes throughout |   |                       | N |   |       |
| > the course of the         |   |                       |   |   |       |
| > experiment?               |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > Is funding available to   |   |                       | Y |   |       |
| > properly dispose of       |   |                       | / |   |       |
| > project wastes throughout |   |                       | N |   |       |
| > the course of the         |   |                       |   |   |       |
| > experiment?               |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > Are biohazards involved   |   |                       | Y |   |       |
| > in the proposed work? If  |   |                       | / |   |       |
| > yes, attach a current     |   |                       | N |   |       |
| > copy of approval from the |   |                       |   |   |       |
| > Institutional Biosafety   |   |                       |   |   |       |
| > Committee.                |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > Can the proposed work be  |   |                       | Y |   |       |
| > carried out within the    |   |                       | / |   |       |
| > existing safety envelope  |   |                       | N |   |       |
| > of the facility (Facility |   |                       |   |   |       |
| > Use Agreement, Nuclear    |   |                       |   |   |       |
| > Facility Authorization    |   |                       |   |   |       |
| > Agreement, Accelerator    |   |                       |   |   |       |
| > Safety Envelope, etc.) in |   |                       |   |   |       |
| > which it will be          |   |                       |   |   |       |
| > performed?                |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > If **no**, attach a       |   |                       |   |   |       |
| > statement indicating what |   |                       |   |   |       |
| > has to be done and how    |   |                       |   |   |       |
| > modifications will be     |   |                       |   |   |       |
| > funded to prepare the     |   |                       |   |   |       |
| > facility to accept the    |   |                       |   |   |       |
| > work.                     |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
|                             |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **5. [TYPE OF               | S |                       |   |   |       |
| WORK]{.underline}**         | e |                       |   |   |       |
|                             | l |                       |   |   |       |
|                             | e |                       |   |   |       |
|                             | c |                       |   |   |       |
|                             | t |                       |   |   |       |
|                             | B |                       |   |   |       |
|                             | a |                       |   |   |       |
|                             | s |                       |   |   |       |
|                             | i |                       |   |   |       |
|                             | c |                       |   |   |       |
|                             | , |                       |   |   |       |
|                             | A |                       |   |   |       |
|                             | p |                       |   |   |       |
|                             | p |                       |   |   |       |
|                             | l |                       |   |   |       |
|                             | i |                       |   |   |       |
|                             | e |                       |   |   |       |
|                             | d |                       |   |   |       |
|                             | o |                       |   |   |       |
|                             | r |                       |   |   |       |
|                             | D |                       |   |   |       |
|                             | e |                       |   |   |       |
|                             | v |                       |   |   |       |
|                             | e |                       |   |   |       |
|                             | l |                       |   |   |       |
|                             | o |                       |   |   |       |
|                             | p |                       |   |   |       |
|                             | m |                       |   |   |       |
|                             | e |                       |   |   |       |
|                             | n |                       |   |   |       |
|                             | t |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
|                             |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **6. [LINK TO TECHNOLOGY    |   |                       |   |   |       |
| TRANSFER OPPORTUNITIES      |   |                       |   |   |       |
| ]{.underline}**             |   |                       |   |   |       |
|                             |   |                       |   |   |       |
| Identify below if the       |   |                       |   |   |       |
| proposal is in support of a |   |                       |   |   |       |
| CRADA, a WFO, or a license  |   |                       |   |   |       |
| agreement with a commercial |   |                       |   |   |       |
| sponsor.                    |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **7. [PREVIOUS PROPOSALS    |   |                       |   |   |       |
| AND FUNDING]{.underline}**  |   |                       |   |   |       |
|                             |   |                       |   |   |       |
| Identify below any          |   |                       |   |   |       |
| proposals for funding       |   |                       |   |   |       |
| submitted for this, or      |   |                       |   |   |       |
| substantially similar,      |   |                       |   |   |       |
| work, whether or not        |   |                       |   |   |       |
| funded. List the amount     |   |                       |   |   |       |
| requested and, if funded,   |   |                       |   |   |       |
| the amount awarded.         |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **8. [POTENTIAL FUTURE      |   |                       |   |   |       |
| FUNDING]{.underline}**      |   |                       |   |   |       |
|                             |   |                       |   |   |       |
| Identify below the Agencies |   |                       |   |   |       |
| and the specific            |   |                       |   |   |       |
| program/office, which may   |   |                       |   |   |       |
| be interested in supplying  |   |                       |   |   |       |
| future funding. Give some   |   |                       |   |   |       |
| indication of time frame.   |   |                       |   |   |       |
| List also any commercial    |   |                       |   |   |       |
| partners who are or may be  |   |                       |   |   |       |
| interested in funding       |   |                       |   |   |       |
| future work.                |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| **APPROVALS**               |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > Department /Division      |   |                       |   |   |       |
| > Administrator             |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > Department Chair/Division |   | Print Name            |   |   |       |
| > Manager                   |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+
| > Cognizant Associate       |   | Print Name            |   |   |       |
| > Director                  |   |                       |   |   |       |
+-----------------------------+---+-----------------------+---+---+-------+

Print Name

**BUDGET REQUEST BY FISCAL YEAR**

*Department*

*Title*

*PI*

(TM funding is intended to bridge a gap of no more than 2 years.)

+---------------------------------+--------+--------+--------+--------+
| **COST ELEMENT**                | **     | **     | **     | TOTAL  |
|                                 | FISCAL | FISCAL | FISCAL | COST   |
|                                 | YEAR   | YEAR   | YEAR   |        |
|                                 | \_\_\_ | \_\_\_ | \_\_\_ |        |
|                                 | \_\_** | \_\_** | \_\_** |        |
+---------------------------------+--------+--------+--------+--------+
| Labor\*                         |        |        |        |        |
|                                 |        |        |        |        |
| Fringe                          |        |        |        |        |
|                                 |        |        |        |        |
| Total Labor                     |        |        |        |        |
|                                 |        |        |        |        |
| Organizational Burden @         |        |        |        |        |
| \_\_\_\_ %                      |        |        |        |        |
+---------------------------------+--------+--------+--------+--------+
| DISTRIBUTED TECHNICAL SERVICES  |        |        |        |        |
+---------------------------------+--------+--------+--------+--------+
| Materials                       |        |        |        |        |
|                                 |        |        |        |        |
| Supplies                        |        |        |        |        |
|                                 |        |        |        |        |
| Travel                          |        |        |        |        |
|                                 |        |        |        |        |
| Services                        |        |        |        |        |
|                                 |        |        |        |        |
| Total MST                       |        |        |        |        |
|                                 |        |        |        |        |
| Materials Burden @ \_\_\_\_%    |        |        |        |        |
+---------------------------------+--------+--------+--------+--------+
| #### TOTAL PROJECT COST         |        |        |        |        |
+---------------------------------+--------+--------+--------+--------+
| \*Labor (give levels of effort  |        |        |        |        |
| with names, or if unknown       |        |        |        |        |
| indicate TBD)                   |        |        |        |        |
|                                 |        |        |        |        |
| **[Scientific &                 |        |        |        |        |
| Professional]{.underline}**     |        |        |        |        |
|                                 |        |        |        |        |
| **[Post Doc]{.underline}**      |        |        |        |        |
|                                 |        |        |        |        |
| **[Other]{.underline}**         |        |        |        |        |
+---------------------------------+--------+--------+--------+--------+
| #### List all                   |        |        |        |        |
|  Materials Costing Over \$5,000 |        |        |        |        |
+---------------------------------+--------+--------+--------+--------+