Grant and Contract Internal Clearance Form

California State University, Long Beach

Rev. 10/17/2007

1. Agency Deadline: (mm/dd/yy) Send Date:    By:
2. Principal Investigator Name: (Last, First, MI) Co-PI(s):
3. PI/PD Dept.: Co-PI Dept:
4. PI Campus Phone:    PI Email:
5. Title of Proposal:
6. Funding Agency:
7. Type of Proposal:    New    Continuation of Grant #:
8. Project Period: (mm/dd/yy) From: To:

Complete Cost-Sharing Addendum if any of the below resources are to be pledged.
9.	Project Budget:	First Year	Second Year	Third Year	Fourth Year	Fifth Year
a.	Direct Costs	$Direct Costs First Year	$ Direct Costs Second Year	$ Direct Costs Third Year	$ Direct Costs Forth Year	$ Direct Costs Fifth Year
b.	+ F&A Costs	$ + F&A Costs First Year	$ + F&A Costs Second Year	$ + F&A Costs Third Year	$ + F&A Costs Forth Year	$ + F&A Costs Fifth Year
c.	(Eff. F&A rate)	(Eff. F&A rate) First Year %	(Eff. F&A rate) Second Year %	(Eff. F&A rate) Third Year %	(Eff. F&A rate) Forth Year %	(Eff. F&A rate) Fifth Year %
d.	= Amt. Req.	$ = Amt. Req. First Year	$ = Amt. Req. Second Year	$ = Amt. Req. Third Year	$ = Amt. Req. Forth Year	$ = Amt. Req. Fifth Year
e.	Total Requested All Years:		$Total Requested	F&A Rate Exception Code:		Budget reviewed by:
f.	Dept./College Personnel	$ Dept./College Personnel First Year	$ Dept./College Personnel Second Year	$ Dept./College Personnel Third Year	$ Dept./College Personnel Forth Year	$ Dept./College Personnel Fifth Year
g.	Dept./College Cash	$ Dept./College Cash First Year	$ Dept./College Cash Second Year	$ Dept./College Cash Third Year	$ Dept./College Cash Forth Year	$ Dept./College Cash Fifth Year
h.	Dept./College In-Kind	$ Dept./College In-Kind First Year	$ Dept./College In-Kind Second Year	$ Dept./College In-Kind Third Year	$ Dept./College In-Kind Forth Year	$ Dept./College In-Kind Fifth Year
i.	Total Divisional Contributions	$ Total Divisional Contributions First Year	$ Total Divisional Contributions Second Year	$ Total Divisional Contributions Third Year	$ Total Divisional Contributions Forth Year	$ Total Divisional Contributions Fifth Year
j.	Total External Contributions	$ Total External Contributions First Year	$ Total External Contributions Second Year	$ Total External Contributions Third Year	$ Total External Contributions Forth Year	$ Total External Contributions Fifth Year
k.	Est. F&A Redistribution	$ Est. F&A Redistribution First Year	$ Est. F&A Redistribution Second Year	$ Est. F&A Redistribution Third Year	$ Est. F&A Redistribution Forth Year	$ Est. F&A Redistribution Fifth Year
F&A charges are earned based on actual project activity. Amounts estimated in the line above may not be returned to Colleges, Departments, and Principal Investigators if they are encumbered as Departmental or College cash matching or if there are expenditure disallowances. (See: Indirect Costs Policy of August 1991 as amended.)

10. Number of students Involved actively and directly: Undergraduates: Graduates:

11. Facilities: On-campus site: Off-Campus Site:

For private foundations or philanthropic funding from corporations and organizations, has your college or unit Director of Development (DOD) obtained prospect clearance? No Yes N/A

If yes, who is your DOD and
approximate date DOD was contacted:

Contractual Agreement with other entities involved in the project ?: No Yes.

Special Permits or Certifications required for Project Personnel? No Yes.

University or Auxiliary Faculty, Staff or Student Travel Outside of the United States ?: No Yes .

Installation of Research Related Equipment ?: No Yes.

If your answer is "yes" above, please indicate where research equipment will be installed .

Physical or utility modifications to primary project locations ?: No Yes.

If your answer is "yes" above, please indicate what modifications to primary project locations are planned

Emergency electrical backup power needed? No Yes.

New or additional facilities or campus services required ?: No Yes.

Changes in current CSU space type classification (e.g. classroom to laboratory, etc.)? No Yes.

Additional security needed for project area? No Yes.

Parking for vehicles and/or equipment needed? No Yes.

Scientific Diving Operations ?: No Yes.

Operation of Medically Related Facilities including Mobile Operations ?: No Yes.

USE OF HAZARDOUS MATERIALS

Laboratory Chemicals or Other Hazardous Materials ?: No Yes. Hazardous materials are defined as substances, materials, or mixtures which by reason of being explosive, flammable, poisonous, corrosive, oxidizing, an irritant, or otherwise harmful, are likely to cause injury or illness. Hazardous materials include hazardous waste as defined in section 5192 (a) (3) and 5194 (3) of the California Code of Regulations (CCR) Title 8. ( www.dir.ca.gov/Title8/sb7g16a109/html )

Blood or Other Potentially Infectious Materials ?: No Yes. This includes the use of human blood, human blood components, and products made from blood and human body fluids visibly contaminated with blood such as saliva. ( www.dir.ca.gov/Title8/5193.html)

Agents or Toxins deemed by HHS/USDA to Pose a Threat to Public, Animal or Plant Health, or to Animal or Plant Products ?:
No Yes. http://a257.g.akamaitech.net/7/257/2422/05dec20031700/edocket.access.gpo.gov/cfr_2003/octqtr/42cfr73.4.htm (primary Select Agents) AND http://a257.g.akamaitech.net/7/257/2422/05dec20031700/edocket.access.gpo.gov/cfr_2003/octqtr/42cfr73.5.htm (Overlap Select Agents)

U.S. Drug Enforcement Administration (DEA) Controlled Substances ?: No Yes.
( http://www.usdoj.gov/dea/pubs/csa/812.htm#c )

Laser, Class 3am3b or 4 ?: No Yes. http://www.laserinstitute.org/publications/safety_bulletin/laser_safety_info/#Laser%20Hazard%20Classification

Radioactive Materials, Radiation Producing Equipment Containing Radioactive Sources?: No Yes:

Recombinant DNA Molecules ?: No Yes. http://www4.od.nih.gov/oba/rac/guidelines_02NIH_Guidelines_Apr02.htm

Bio-Hazardous Materials ?: No Yes.
( http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=117001-118000&file=117625-117780)

Medical Waste ?: No Yes. This includes material that is generated or produced as a result of diagnosis, treatment, or immunization of human beings or animals and includes sharps waste such as hypodermic needles, blades, or needles with attached tubing, syringes contaminated with biohazardous materials.
( http://leginfo.ca.gov/cgi-bin/displycode?section=hsc&group=117001-118000&file=117625-117780)

Carcinogens ?: No Yes. These are chemicals known to the state to cause cancer or reproductive toxicity.
( http://www.oehha.org/prop65/CRNR_notices/list_changes/pdf/111403olsta.pdf )

Compressed Gas Cylinders or cryogenic liquids ?: No Yes.

Use of Animals: No Yes . If "Yes," your signature below certifies (1) that you have read University policies on the use of animals in research, (2) that you have provided the Office of University Research with an Animal Use Assurance, (3) that as soon as possible, but not later than notification of funding, you will (a) submit to the CSULB Animal Welfare Board a proposed protocol for use of animal subjects, (b) complete the CSULB Responsible Conduct of Research Orientation, and (4) that you will furnish the Director for Research Compliance, upon request, verification of compliance with University policies and the approved protocol.

Use of Human Subjects: No Yes . If "Yes," your signature below certifies (1) that you have read the CSULB IRB Manual, (2) that as soon as possible, but not later than notification of funding, you will (a) submit to the Institutional Review Board for the Protection of Human Subjects (IRB) a proposed protocol for use of human subjects, (b) complete the CSULB Responsible Conduct of Research Orientation, and (4) that you will furnish the Director for Research Compliance, upon request, verification of compliance with federal and University policies governing use of human subjects and the approved protocol.

Conflict of Economic Interests: Your signature below indicates that you have read and complied with the "General Instructions for Disclosures of Economic Interests Relating to Externally-Sponsored Activities." Have you completed the federal form, if submitting to the NIH or NSF, or the CSU/State form, if submitting to a non-governmental agency? Yes, or Not Applicable.
Instructions and disclosure forms are available on-line here.

Principal Investigator's Statement of Cost-Sharing: My checkmark at the end of this statement and my signature below indicate that I have included all commitments of personnel time and physical resources of the University or third parties that are stated in the proposal narrative in the project budget either as direct costs or cost-sharing and these are correctly stated in the proposal budget, in the budget summary on the first page of this clearance document, and in the attached Cost-Sharing Addenda.

Principal Investigator 's Statement of General Responsibilities: In addition to the specific concerns addressed in this Clearance Form, my checkmark here and signature below indicate that I will comply with all University and Foundation policies regarding Drug-free Environment, Misconduct in Scholarship, Use of Recombinant DNA Molecules, Affirmative Action, and all University and Foundation policies governing the conduct of fiscal and personnel affairs for grants and contracts as Principal Investigator. In addition to certifying the completeness and accuracy of the information given in this Clearance Form, I understand that it is my responsibility as PI or Principal Investigator to manage expenditures within the limits of the budget provided by the sponsoring agency which includes all matching commitments.

Signature by Email: Transmission or forwarding of this document through a personal CSULB email account constitutes "electronic signature" and is binding on the person to whom the email account has been assigned. These "electronic signatures" are consided dated as of the date of the email. Indicate your "signature name" and "email account name" in the appropriate boxes below.

Every person signing this Internal Clearance Form (or forwarding its output document through email) should have reviewed at a minimum the information contained in this checklist, the complete and final budget, the final budget narrative, if any, and an extended abstract/outline/or rough draft narrative of the purpose and proposed activities for which funding is sought.

You will be notified by telephone and/or email by the Associate Vice President for Research and External Support or her/his designee when the proposal has been approved for submission. (Approved clearance form, with log number, will be sent to the Principal Investigator when the finished proposal is received in the Office of University Research.)

	Signature Name:	Email Address:
1. Applicant 1: (PI)	Applicant 1: (PI) Signature Name	Applicant 1: (PI) Email Address
Applicant 2: (if Co-PI)	Applicant 2: (if Co-PI) Signature Name	Applicant 2: (if Co-PI) Email Address
Applicant 3: (if Co-PI)	Applicant 3: (if Co-PI) Signature Name	Applicant 3: (if Co-PI) Email Address
2. Manager of Unit Providing Budgeted Services:	Manager of Unit Signature Name	Manager of Unit Email Address
3. Department Chair 1:	Department Chair 1 Signature Name	Department Chair 1 Email Address
Department Chair 2: (for Co-PI)	Department Chair 2: (for Co-PI) Signature Name	Department Chair 2: (for Co-PI) Email Address
Department Chair 3: (for Co-PI)	Department Chair 3: (for Co-PI Signature Name	Department Chair 3: (for Co-PI Email Address
4. College Fiscal Officer 1:	College Fiscal Officer 1: Signature Name	College Fiscal Officer 1: Email Address
College Fiscal Officer 2: (for Co-PI)	College Fiscal Officer 2: (for Co-PI) Signature Name	College Fiscal Officer 2: (for Co-PI) Email Address
College Fiscal Officer 3: (for Co-PI)	College Fiscal Officer 3: (for Co-PI) Signature Name	College Fiscal Officer 3: (for Co-PI) Email Address
5. College Dean or Designee 1:	College Dean or Designee 1 Signature Name	College Dean or Designee 1 Email Address
College Dean or Designee 2: (for Co-PI)	College Dean or Designee 2: (for Co-PI) Signature Name	College Dean or Designee 2: (for Co-PI) Email Address
College Dean or Designee 3: (for Co-PI)	College Dean or Designee 3: (for Co-PI) Signature Name	College Dean or Designee 3: (for Co-PI) Email Address
6. CSULB Foundation	CSULB Foundation Signature Name	CSULB Foundation Email Address
7. AVP for Financial Management	Signature Name	Email Address
8. Interim AVP for Research & Ext Support	Signature Name	Email Address
Comments:

Important: Before submitting this form, please print out a copy on your local printer.
This Electronic version of the Internal Clearance Form will submit directly to the Office of University Research, which in turn will forward the output document to the first-named Principal Investigator, who will forward the email to the next appropriate person in the sign-off sequence. The Dean will forward the email back to the Office of Research, which will obtain Foundation review of the proposal budget and Clearance Form. Each person forwarding this email document is requested to follow-up immediately with a telephone message to the addressee. The final document will contain the forwarding history for validation of electronic signature.

Please note that the output document does not look like the form; it is a simple list of the questions and the answers See sample.

The Associate Vice President for Research and External Support and the Associate Vice President for Financial Management, will authorize submission of a proposal only when the Internal Clearance Form is complete and all questions about it satisfied.