**Date of Proposal (MM/DD/YY):**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Reagent Request:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Purpose/Objective:** (please provide a brief one to two paragraph
description of the proposed project. Include justification and relevant
background)

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Principal Investigator:

  ---------------- ------------------------------------------------------
  Name             

  Position:        

  Address:         

  State            

  ZIP Code         

  Telephone        

  Fax              

  E-Mail           
  ---------------- ------------------------------------------------------

Organization/Company:

  ---------------- ------------------------------------------------------
  Name:            

  Address:         

  State            

  ZIP Code         
  ---------------- ------------------------------------------------------

**Description of Collection - please provide Excel Spreadsheet
detailing:**

-   Year

-   Isolate

-   Storage Method

-   Host

-   Amplification Method

-   Genomic RNA Extraction Method

-   Unique Number Code for Each Isolate

**Description of Reagent Repository (if applicable):**

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**Proposed Methods and Protocols to Prepare Reagents:**

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**Quality Control for Reagents:**

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Detailed Budget for Total Number of Reagents, with final costs and a
cost/reagent in US dollars:

  ------------------------------------------------------ ----------------
  Annual Budget Estimate                                 Amount

  Cell culture amplification (media, cells, T75 cm2      
  flasks, consumables)                                   

  Per Isolate                                            \$

  Per XXX number of isolates                             \$

  RNA extraction of 10 ml of cell culture supernatant    
  (NASBA reagents, consumables)                          

  Per isolate                                            \$

  Per XXX number of isolates \$                          \$

  Quality Control (RT-PCR kit, consumables, agarose      
  gels, buffers)                                         

  Per isolate                                            \$

  Per XXX number of isolates                             \$

  Total technical costs per isolate                      \$

  Total technical costs per total isolates per year      \$

  Shipping                                               

  Per shipment                                           \$

  Personnel costs                                        

  Base salary/Fringe costs                               \$

  Indirect costs                                         \$

  Total Costs                                            \$

  Total Cost/Isolate                                     \$
  ------------------------------------------------------ ----------------

**Dates of Proposed Period of Reagent Preparation: (MM/DD/YY -
MM/DD/YY)**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Timeline for Shipping Reagents (Estimate the number of reagents
shipped per month and start date for shipping reagents):**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Human Subjects or Animal Subjects Approvals, if necessary, and provide
documentation as IACUE and IRB approvals:**

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**Agree to NIAID's Microbial Sequencing Center Data Release Policy**

Yes \_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_

Principal Investigator Signature:

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Institutional Official Signature:

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NIAID Project Officer

Maria Y. Giovanni, Ph.D.

Assistant Director for Microbial Genomics & Advanced Technology

Division of Microbiology and Infectious Diseases

NIAID/NIH/DHHS

6610 Rockledge Dr. MSC 6603; Room 6007

Bethesda, MD 20892-6603

301-496-1884 Phone

301-480-4528 FAX

<mgiovanni@niaid.nih.gov>

NIAID Contract Officer

Liem Nguyen\
Preclinical Research Contracts Branch\
CMP, DEA, NIAID, NIH, DHHS\
6700-B Rockledge Drive, #3229, MSC 7612\
Bethesda, MD 20892-7612\
301-451-3687 Phone\
301-480-2622 (FAX)

NIH Scientific Coordinator or other Additional Scientific Coordinators:

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