JHU SCHOOL OF MEDICINE SUBAWARD & SUBCONTRACT INFORMATION SHEET Please submit cmpleted sub infsheets (in WORD), the signature page (PDF), and ther required dcuments t ORASUBCONTRACTS@jhmi.edu. JHU Cntact Infrmatin RSA Department: Medicine Infectius Diseases JHU Principal Investigatr Name (need credentials): Gerge Washingtn Address /Suite: 1550 Orleans St, Rm 100 City, State, Zip Baltimre, MD 21287 Phne Number: 410-955-3507 E-mail Address: gwash1@jhmi.edu Respnsible Cst Center: 1704612501 JHU Departmental Cntact fr Study Questins Katherine Newkirk Address/Suite: 1830 E. Mnument St City, State, Zip Baltimre, MD 21287 Phne Number: 410-614-0923 E-mail Address: kbnewkirk@jhmi.edu RSA JHU Cntact fr Invicing/Reprts/Gds Receipts Katherine Newkirk Address/Suite:1830 E. Mnument St City, State, Zip Baltimre, MD 21287 Phne Number: 410-614-0923 E-mail Address: kbnewkirk@jhmi.edu JHED ID/SAP ID: kbarlw2 "fully executed" Additinal JHU Cntacts t receive FE Subsite Cntact Infrmatin Subsite Legal KwaZulu Natal Research Institute fr HIV and Tuberculsis Subsite Principal Investigatr Name (need credentials): Martha Washingtn Phne Number: +078 390 2541, +031 260 4073 E-mail Address: Martha.Washingtn@k-rith.rg Subsite Research Administratin Office Cntact Jhn Adams, Research Grants Officer Address: Nelsn R. Mandela Schl f Medicine, University f KwaZulu-Natal K-RITH Twer Bldg, Lvl 3 Private Bag X7, Cngella 4013 Suth Africa Phne Number: +27 31 260 4113 E-mail Address: Jhn.Adams@k-rith.rg Subsite Payment Remittance Address Dept/Building name, Suite: Nelsn R. Mandela Schl f Medicine, University f KwaZulu-Natal K-RITH Twer Bldg, Lvl 3 Page 1 f 6 (ver 10.1.13)
Street Address: Private Bag X7, Cngella 4013 City, State, zip: Suth Africa Prime Award Infrmatin Grantr Dris Duke Charitable Fundatin Spnsr Award Number: 6778-13 Prime Award Current Budget Perid: 01/01/14-12/31/14 SAP Grant #:112233 Shuld nt be #96, COEUS IPN #: 12053164 subs ffice will IO # (900#):90001234 dcument that n last page Additinal Details A. FINANCIAL Usually matches award perid 1. Subsite New Budget Perid: 03/01/13-12/31/14 2. Fr the new budget perid, hw much will JHU pay the subsite (subsite direct csts + subsite indirect csts, nt including any carryver $)? $0, it s a NCE Hw much are yu increasing the "award ceiling"? 3. Des this subaward include any funding carried ver frm a previus budget year? Yes a. If the answer is yes, d nt include carryver $ n the budget frm b. If the answer is yes, hw much? $71,084.63 c. $ is being carried ver frm what year (mm/dd/yyyy)? 03/01/12-02/28/13 d. $ is being carried ver int what year (mm/dd/yyyy)? 03/01/13-12/31/14 This is the amunt unspent at the end f the prir perid. Yu can (check allwability) allw carryver here. 4. Is the IO# given in the Prime Award Infrmatin an allcatin accunt? N a. If s, please prvide the Master accunt#. 90001234 5. Are there ther subs t this subsite under this grant? n Prir Perid New Perid, shuld match #A.1 6. Will the site get any start-up funds upn executin f the subagreement? n/a If the answer is yes, hw much? B. REGULATORY 1. Please prvide the site s DUNS number. 637360244 2. Will the wrk under this subagreement invlve human subjects? n 3. Will there be disclsure t the subsite f individually identifiable health infrmatin? n 4. Will the wrk under the sub invlve vertebrate animal research? n Page 2 f 6 (ver 10.1.13)
Likely will need the PI t fill ut this sectin unless yu have a NCE C. STUDY-RELATED 1. What perfrmance milestnes r deliverables (i.e. reprts, samples, patient data) is the site expected t deliver? COMPLETE THE TABLE BELOW: (MANDATORY FOR YEAR 1, COMPETING RENEWALS, REVISED SOW S!!) DELIVERABLE DUE DATE OR TIME FRAME EXPECTED N/A (NCE) Fr any new applicatins with subs, be sure t ask fr a detailed wrkscpe with the deliverables, it will save time when awarded. 2. Will the subsite be cnducting a clinical trial? n If the answer is yes, please answer the fllwing: a. Is the prtcl investigatr initiated? b. Hw many ttal patients is the site expected t recruit? c. If patient ttal is unknwn, is there an enrllment cap? If yes, what is the cap? d. Is there a minimum? If yes, what is the minimum? e. Will the site be paid a per-patient amunt? If yes, hw much? f. Will the site be paid any fixed csts? If yes, hw much? g. Will the site be paid fr a patient s partial cmpletin f the trial? Hw much? h. Is payment cntingent upn submissin f case reprt frms r ther data? i. If yes, will the site still have t submit invices? j. Des the site submit CRF s befre / at the same time as invices? k. Will the site be required t submit any ther technical reprts, financial reprts, and/r final reprts? l. If yes, what are they?, when are they due? 3. Is a study drug being supplied t the subsite? n If the answer is yes, please answer the fllwing: a. Where it is frm? b. Des JHU have an agreement with the Pharmaceutical cmpany? c. Will JHU send it t the subsite r will it be sent by the ther entity (i.e. a pharmaceutical cmpany)? 4. Will any ther physical materials (i.e. cells, samples, etc.) be shipped t the subsite by JHU? n a. Were the materials generated/invented/created by JHU as a result f this study/prject? b. What are the materials? 5. Is any equipment being supplied/sent t the subsite? n If the answer is yes, please answer the fllwing: a. Where it is frm? b. Wh will wn it? Page 3 f 6 (ver 10.1.13)
c. If nt wned by the site, are there plans fr the wner t remve it frm the site? While yu are filling ut this frm t set up r cntinue a sub, please send the fllwing t yur subsite as the infrmatin may have changed since the riginal applicatin: T Sub PI and/r Sub Admin cntact: I am wrking with ur subs ffice t get an agreement t yu s that yu can begin t invice us fr the current perid fr "Prject Title" with Dr. X. Can yu please supply me with the fllwing cntact infrmatin: PI cntact infrmatin Phne number Wrk email (if different) Research Administratin Office Cntact Name Address Phne Number Email Payment Remittance Address {Additinally, yu may als need t request an updated SOW with deliverables table, revised budget (due t cuts), any IRB/IACUC apprvals and pssibly a wire transfer frm if freign.} Page 4 f 6 (ver 10.1.13)
Required Attachments Significant Financial Interest Frm ( SFI fr Federal Prime Awards) The subsite shuld cmplete and return the SFI t the dept if a Subrecipient Cmmitment Frm ( SCF ) was nt cmpleted at the time f JHU applicatin. The dept may submit the SCF if it was cmpleted at time f applicatin instead f the SFI when submitting all the required paperwrk t the Subawards team. The SFI/SCF is nly required fr Subawards under Federal Prime Awards. Statement f Wrk ( SOW ) The SOW will serve as the gauge t determine whether the subsite adequately perfrms the wrk under the sub. This dcument shuld prvide a cncise explanatin f the purpse f the wrk t be perfrmed by the subsite, as well as a descriptin f what JHU will be paying fr. Fr example, if the subsite is suppsed t submit data, samples, etc. t JHU, the SOW shuld state that fact. If the site is participating in a clinical trial, the SOW shuld state hw many patients the site is expected t recruit, and what data and/r case reprt frms the subsite must submit t JHU in rder t be paid. All deliverables expected frm the subsite shuld be included in the SOW. Please bear in mind that the SOW shuld be in terms understandable t the lay persn and must be mre detailed than a general descriptin f the whle prject. Budget Please prvide a budget fr the subsite. The budget shuld include the name f the subsite, the sub-pi, dates, and the titles (and preferably the names) f any ther persnnel wh will be receiving salary supprt. If the budget includes funding fr Supplies r Other Expenses, it shuld prvide a breakdwn f any such funding exceeding $1,000. Any travel csts shuld als be explained. IRB/IACUC Apprval (if applicable) If the sub-pi will be wrking with Vertebrate Animals and/r cnducting human subjects research, please prvide a cpy f the subsite s IRB and/r IACUC apprval. The expiratin date fr the apprval(s) must fall within r after the current budget year. If the sub site des nt have an IRB cmmittee, the sub-pi shuld be added t the JHU PI s e-irb prtcl, and prf f additin with JHU apprval number and expiratin date shuld be prvided. Wire Transfer Authrizatin A Wire Transfer Authrizatin frm is necessary fr the Purchasing department t set up purchase rders fr freign sites. The subsite shuld fill ut the tp sectin. The WTA is nly required fr the Original Subaward t a freign site, r if the WTA infrmatin changes at the time f a mdificatin. By signing this frm, I acknwledge that JHU will enter int a subaward/subcntract fr which I will be respnsible, and that spnsred funding awarded t JHU fr my research will be used t pay the csts f the subaward/subcntract. In additin, I have reviewed and apprved the Statement f Wrk and Budget submitted as attachments t this frm. JHU Principal Investigatr Dr. Gerge Washingtn Printed Name Signature Page 5 f 6 (ver 10.1.13) Date
ORA USE ONLY Inf frm Dept Received: Sub Type: Vendr #: 96# Requested: Sub IO #SC Requested/PO rev: JHU PO #: Cumulative Ttal f Sub/PO: IRB Expiratin Date: ; Exempt: IACUC Expiratin Date: Sub Drafted: Sub E-Mailed: Executed Sub Received: Executed t Dept.: Page 6 f 6 (ver 10.1.13)