+----------------+----------------+----------------+----------------+
| DEPARTMENT OF  | RFP/CONTRACT   |                |                |
| HEALTH AND     | NUMBER         |                |                |
| HUMAN SERVICES |                |                |                |
|                |                |                |                |
| PUBLIC HEALTH  |                |                |                |
| SERVICE        |                |                |                |
|                |                |                |                |
| NATIONAL       |                |                |                |
| INSTITUTES OF  |                |                |                |
| HEALTH         |                |                |                |
|                |                |                |                |
| **PROPOSAL     |                |                |                |
| SUMMARY AND    |                |                |                |
| DATA RECORD**  |                |                |                |
+----------------+----------------+----------------+----------------+
| PROJECT TITLE  |                |                |                |
| (Title or RFP  |                |                |                |
| or Contract    |                |                |                |
| Proposal)      |                |                |                |
+----------------+----------------+----------------+----------------+
| LEGAL NAME AND | PLACE OF       |                |                |
| ADDRESS OF     | PERFORMANCE    |                |                |
| OFFEROR        | (Full address  |                |                |
|                | including ZIP) |                |                |
+----------------+----------------+----------------+----------------+
| TYPE OF        |                |                |                |
| CONTRACT       |                |                |                |
| PROPOSED       |                |                |                |
|                |                |                |                |
| 9              |                |                |                |
| COST           |                |                |                |
| -REIMBURSEMENT |                |                |                |
| 9 FIXED PRICE  |                |                |                |
| 9              |                |                |                |
| COST-          |                |                |                |
| PLUS-FIXED-FEE |                |                |                |
| 9 OTHER        |                |                |                |
+----------------+----------------+----------------+----------------+
| ESTIMATED TIME |                |                |                |
| REQUIRED TO    |                |                |                |
| COMPLETE       |                |                |                |
| PROJECT        |                |                |                |
+----------------+----------------+----------------+----------------+
| ESTIMATED      | PROPOSED       |                |                |
| DIRECT COSTS   | STARTING DATE  |                |                |
| IN PROPOSED    |                |                |                |
| YEAR (From     |                |                |                |
| Budget)        |                |                |                |
+----------------+----------------+----------------+----------------+
| DOES THIS      |                |                |                |
| PROPOSAL       |                |                |                |
| INCLUDE A      |                |                |                |
| SUBCONTRACT 9  |                |                |                |
| YES 9 NO (If   |                |                |                |
| yes, please    |                |                |                |
| furnish name   |                |                |                |
| and location   |                |                |                |
| of             |                |                |                |
| organization,  |                |                |                |
| description of |                |                |                |
| services,      |                |                |                |
| basis for      |                |                |                |
| selection,     |                |                |                |
| responsible    |                |                |                |
| person         |                |                |                |
| employed by    |                |                |                |
| subcontractor  |                |                |                |
| and cost       |                |                |                |
| information.)  |                |                |                |
+----------------+----------------+----------------+----------------+
| NAME AND TITLE | SOCIAL         | EST. HOURS     | AREA           |
| OF PRINCIPAL   | SECURITY NO.   | WEEKLY         | CODE/TEL.NO.   |
| INVESTIGATOR   |                |                |                |
+----------------+----------------+----------------+----------------+
| NAME AND TITLE |                |                |                |
| OF             |                |                |                |
| C              |                |                |                |
| O-INVESTIGATOR |                |                |                |
| (Use           |                |                |                |
| attachment if  |                |                |                |
| necessary.)    |                |                |                |
+----------------+----------------+----------------+----------------+
| NAME AND TITLE | AREA           |                |                |
| OF             | CODE/TELEPHONE |                |                |
| INDIVIDUAL(S)  | NUMBER         |                |                |
| AUTHORIZED TO  |                |                |                |
| NEGOTIATE      |                |                |                |
| CONTRACTS      |                |                |                |
+----------------+----------------+----------------+----------------+
| NAME AND TITLE | AREA           |                |                |
| OF             | CODE/TELEPHONE |                |                |
| INDIVIDUAL(S)  | NUMBER         |                |                |
| AUTHORIZED TO  |                |                |                |
| EXECUTE        |                |                |                |
| CONTRACTS      |                |                |                |
+----------------+----------------+----------------+----------------+

DOES THIS PROPOSAL INVOLVE EXPERIMENTS WITH HUMAN SUBJECTS 9 YES 9 NO

Institution's General Assurance re: Human Subjects DATE APPROVED [
]{.underline} 9 PENDING

Institution's Review Board's Approval of this Proposal DATE APPROVED [
]{.underline} 9 PENDING

An example of the informed consent for this study is enclosed 9 YES 9 NO

A Clinical Protocol is enclosed 9 YES 9 NO

  --------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- --------------- ------
  OFFEROR'S ACKNOWLEDGMENT OF AMENDMENTS TO THE RFP (Use attachment if necessary)                                                                                                                     
  ERRATA NUMBER                                                                     DATE                                                                                              ERRATA NUMBER   DATE
  NAME, ADDRESS, AND PHONE NUMBER OF COGNIZANT GOVERNMENT AUDIT AGENCY              NUMBER OF EMPLOYEES CURRENTLY EMPLOYED                                                                            
                                                                                    DOLLAR VOLUME OF BUSINESS PER ANNUM                                                                               
                                                                                    THIS OFFER EXPIRES [ ]{.underline} DAYS FROM THE DATE OF THIS OFFER (120 days if not specified)                   
  --------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- --------------- ------

FOR THE INSTITUTION

  --------------------------------------------- --------------------------------------
  SIGNATURE OF PRINCIPAL INVESTIGATOR           SIGNATURE OF BUSINESS REPRESENTATIVE
  TYPED NAME AND TITLE                          TYPED NAME AND TITLE
  EMPLOYER IDENTIFICATION NUMBER/ DUNS NUMBER   DATE OF OFFER
  --------------------------------------------- --------------------------------------

NIH 2043 (Rev 6/82)

Provision of the Social Security Number is voluntary. Social Security
Numbers are requested for the purpose of accurate and efficient
identification, review, and management of NIH Extramural Programs.
Authority for requesting this information is provided by Title III,
Section 301, and Title IV of the Public Health Service Act, as amended.

NIH 2043 (Rev 6/82) BACK