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Internal Clearance Form (ICF)

PI must submit Completed and Signed ICF to ORGS with each application for funding prior to Submission Deadline

Proposals that were submitted to external sponsors without first completing the Internal Clearance Form may be withdrawn or refused at the discretion of the AVP of Research

Investigator Informaton

Principal Investigator/Project Director Name*
Add Co-PIs*
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Co-PI #1

Co-PI #1 Name*

Co-PI #2

Co-PI #2 Name*

Co-PI #3

Co-PI #3 Name*

Project Information

Type of Submission*
Proposed Project Start Date*
Proposed Project End Date*
Flow-Through only
Proposal Deadline*
Is this a Collaborative Proposal*

Budget Information

$
Cost Share Required/Included?*
Cost share cannot be volunteered

If not using FGCU's federaly approved indirect Cost Rate of 42% MTDC, select one of the other options.

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If rate is sponsor designated/not allowed by sponsor, please upload RFP or other grant documentation confirming this. If Indirect is to be used as match, please upload email approval from AVP for Research (please note: emails must be uploaded as a PDF document).

Does this proposal involve one or more Departmentally Approved Course Buyout(s) for FGCU faculty?*
If Yes, list faculty name(s), department(s) and number of credits
Does the work on this project involve any foreign entities or foreign researchers?*
If Yes, please complete the information below. Attach a separate sheet if there are more than two foreign researchers. Be sure to explain the scope of work and role for the foreign researcher(s) listed.
Do you currently have any independent contracts with any foreign entity or work that involves foreign entities?*
If Yes, please complete the information below. Attach a separate sheet if there are more than two foreign researchers. Be sure to explain the scope of work and role for the foreign researcher(s) listed.
Your initial indicates that you have responded truthfully regarding foreign researchers and foreign entities.

Compliance

Does this proposal meet the definition of Fundamental Research (basic and applied research in science and engineering, the results of which ordinarily are published and shared broadly within the scientific community)?*
This Project involves the following
Check all that apply. Checking any box invokes the requirement for the PI to submit the materials to the appropriate offices or committees for review in accordance with University Policy or Guidelines.

International Information – if any boxes referring to international information are checked, the appropriate Export Control Form must be completed.  See the Export Controls page on the Research and Sponsored Programs website. The information and rules apply to funded and nonfunded projects.

International Travel – If International Travel is checked, the PI and any other traveler must consult with the FGCU International Services Office on university policies and procedures supporting academic related international travel.  International travel preparations will require advanced planning to ensure appropriate immigration, risk management and university support services are in place. The Travel Authorization Request (TAR) must be submitted at least 30-days prior to travel for international travel.  PI is responsible for knowing and complying with all host country requirements and protocols for conducting research at destinations outside of the U.S.

Financial Conflict of Interest – All investigators have read and understand Financial Conflict of Interest in Sponsored Research and have made all required disclosures. Please complete the Financial Conflict of Interest Form.

Principal Investigator/Project Director Disclosures and Assurances

All applicable items contained in the Compliance Checklist have been identified. Investigators agree to abide by any obligations that university policies, guidelines, or legal requirements governing these items may envoke (e.g. obtaining approval for protocols, abiding by export control laws, maintaining confidentiality, etc.)*
I agree that I am the employee responsible for the preparation of the proposal submitted. The information submitted within the proposal is true, complete, and accurate.*
I agree that I have not made false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.*
I agree to accept responsibility for the scientific conduct of the project and to provide the required progress and effort reports if a grant is awarded as a result of the application.*
I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by any Federal department or agency.*
I have not been convicted of, or had a civil judgment rendered against me for the commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public transaction or contract under a public transaction.*
I am not in violation of federal or state antitrust statutes.*
I have not been convicted of or had a civil justment rendered agains me for the commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.*
I presently have not been indicted or otherwise criminally or civilly charged by a government entity (federal, state, local) with commission of any offenses.*
I have not, within a three-year period preceding this application had one or more public transactions (federal, state, local) terminated for cause or default.*
I have read and understand the policies and regulations of financial conflict of interest, including institutional policy.*
I certify that the proposed research work will be performed in compliance with sponsor and institutional policies, procedures and requirements. If the proposal is funded and accepted by the university, I will conduct the project in accordance with the terms and conditions of the sponsoring agency, guidelines and policies of the unviersity and I will be fully responsible for meeting the requirements of the award, including, but not limited to, provding the proper stewardship of sponsored funds, submitting all required technical reports and deliverables on a timely basis, properly disclosing all inventions, and adhering to all federal compliance requirements (e.g. Export Control, HIPAA, Human Research Participants, etc.).*
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Date*

Assignment of Credit

The objective of this section below is to assign credit to the research areas listed below. The information provided identifies particular areas of investigation for data collection.  Primary Investigators should be identified in the top row of the table below. Use whole percentages for all entries identifying the percent of responsibility of each person in the proposed areas. These percentages need not represent salary or time distributions. Add a section for each investigator as needed.

Make sure that the Project Grand Total equals 100%

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Primary Investigator Assignment of Credit

PI
Name*

Co-Investigator #1 Assignment of Credit

Co-PI #1
Name*

Co-Investigator #2 Assignment of Credit

Co-PI #2
Name*

Co-Investigator #3 Assignment of Credit

Co-PI #3
Name*

Grand Total for Project Assignment of Credit

Grand Total for Project Assignment of Credit Must Equal 100%

I affirm that the Grand total for the Project Assignment of Credit is equal to 100%.

The Grand Total above equals 100%*

File Attachment

Attach Project Summary/Abstract, Budget, Budget Justification and other required documentation in ONE pdf document.

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Conflict of Interest

Proposals that were submitted to external sponsors without first completing the internal clearance process may be withdrawn at the discretion of the AVP for Research


Pursuant to Federal regulations, the Principal Investigator certifies to the following statements:

1. The information submitted within the application is true, complete, and accurate.

2. Any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

3. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress and effort reports if a grant is awarded as a result of the application.

I certify that:

a. I am not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by any Federal department or agency.

b. I have not, within a three-year period preceding the application, been convicted of, or had a civil judgment rendered against me for:

i. Commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public transaction or contract under a public transaction;

ii. Violation of federal or state antitrust statutes; or

iii. Commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property.

c. I presently, have not been indicted or otherwise criminally or civilly charged by a government entity (federal, state, local) with commission of any of the offenses enumerated in (4) above or,

d. I have not, within a three-year period preceding this application had one or more public transactions (federal, state, local) terminated for cause or default.

4. I have read and understand the policies and regulations of conflict of interest, including institutional policy.

5. I certify that the proposed research work will be performed in compliance with sponsor and institutional policies, procedures and requirements.

Do you, your spouse, domestic partner or children have a financial interest which may directly and significantly affect the design, conduct or reporting of this project?*

The PI's Department Chair/Center Director and Dean or Division Head must review and sign this form. Upon submission, the form will be forwarded to the people listed below.

Name of PI's Department Chair or Center Director*
Name of PI's Dean or Division Head*
Name of Co-PI's Dean or Division Head*
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Date*

Assurance from Department Chair

The application identified above has been reviewed by the undersigned. The review included the overall budget request, allowability of direct cost charging, individual commitments of effort, rates of compensation, stipend levels, requests for equipment and justification presented, and allocation of adequate space and facilities. Approval is given for the proposed activities to be undertaken in this unit by the personnel identified in the proposal, and for any cost sharing as described in the budget plan.

Name of Department Chair or Center Director*
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Date*

Assurance from College Dean or Authorized Representative

The application identified above has been reviewed by the undersigned. The review included the overall budget request, allowability of direct cost charging, individual commitments of effort, rates of compensation, stipend levels, requests for equipment and justification presented, and allocation of adequate space and facilities. Approval is given for the proposed activities to be undertaken in this unit by the personnel identified in the proposal, and for any cost sharing as described in the budget plan.

Name of College Dean or Division Head*
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Date*

Assurance from Co-PI College Dean or Authorized Representative

The application identified above has been reviewed by the undersigned. The review included the overall budget request, allowability of direct cost charging, individual commitments of effort, rates of compensation, stipend levels, requests for equipment and justification presented, and allocation of adequate space and facilities. Approval is given for the proposed activities to be undertaken in this unit by the personnel identified in the proposal, and for any cost sharing as described in the budget plan.

Name of Co-PI College Dean or Division Head*
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Date of Co-PI Signature*

Assurance from ORGS Director

The application identified above has been reviewed by the undersigned. The review included the overall budget request, allowability of direct cost charging, individual commitments of effort, rates of compensation, stipend levels, requests for equipment and justification presented, and allocation of adequate space and facilities. Approval is given for the proposed activities to be undertaken in this unit by the personnel identified in the proposal, and for any cost sharing as described in the budget plan.

Name of ORGS Approver*
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Date*