SUBRECIPIENT CERTIFICATION FORM

Transcription

1 Our records indicate that your organization is currently being considered for receipt of a subaward under sponsored project funds awarded to the University of Washington. Please check all applicable Certifications in Section A and attach requested information. Additionally, OMB Circular A-133 (A-133) requires the University of Washington (UW) to ensure that your organization is in compliance with the requirements of A-133. As such, please check all applicable Audit Questions in Section C or Section D and attach requested information. If your organization has previously completed this form in the current fiscal year, please skip Section C and Section D. SUBRECIPIENT S LEGAL NAME: ENTITY S FISCAL YEAR START DATE: ENTITY S FISCAL YEAR END DATE: SUBRECIPIENT S PI: UW s PI: PRIME SPONSOR: UW PROPOSAL TITLE: SUBRECIPIENT S TOTAL FUNDS AWARDED: SUBRECIPIENT S PERFORMANCE PERIOD: BEGIN: END: SECTION A - Certifications 1. Human Subjects: Yes No Approval Date: If "Yes": Copies of the IRB approval and approved "Informed Consent" form must be provided before any subaward will be issued. Please attach or provide these documents to UW s PI as soon as they become available. This is required before any subaward will be issued. If "Yes" and NIH funding is involved: Have all key personnel involved completed Human Subjects Training? Yes No Note: All key personnel engaged in human subject research must take the NIH human subjects training or human subject research training ( 2. Animal Subjects: Yes No Approval Date: If "Yes": A copy of the IACUC approval must be provided before any subaward will be issued. Please attach or provide these documents to UW s PI as soon as they become available. 3. Stem Cells: Yes No (If Yes : A copy of the Stem Cell approval must be provided before any subaward will be issued. Please attach or provide these documents to UW s PI as soon as they become available. 4. Conflict of Interest (applicable to NIH, NSF, or other program requiring federal financial disclosure). Please mark appropriate box, as applicable. Not applicable. This project is not being funded by NIH, NSF, or any other program requiring federal financial disclosure. Subrecipient Organization/Institution certifies that it has an active and enforced conflict of interest policy that is consistent with the provision of 42 CFR Part 50, Subpart F Responsibility of Applicants for Promoting Objectivity in Research. Subrecipient also certifies that, to the best of Institution s knowledge, (1) all financial disclosures have been made related to the activities that may be funded by or through a resulting agreement, and required by its conflict of interest policy; and, (2) all identified conflicts of interest have or will have been satisfactorily managed, reduced or eliminated in accordance with subrecipient s conflict of interest policy prior to the expenditures of any funds under any resultant agreement. Subrecipient does not have an active and/or enforced financial conflict of interest (FCOI) policy that complies with PHS FCOI regulations. Subrecipient hereby requests that its project investigators be permitted to make financial interest disclosures to the UW in accordance with the UW s FCOI policy ( Use of the UW s FCOI policy requires the prior written permission of the UW, which will be granted only in exceptional cases. All requests to use the UW FCOI policy should be directed to the UW Office of Research, research@uw.edu, Page 1 of 5

2 5. Cost Sharing/Matching/In-Kind: Yes No Amount: Cost sharing, Matching, and/or In-Kind amounts and justification should be included in the subrecipient s budget 6. Certification Regarding Debarment and Suspension Is the entity, PI or any other employee or student participating in this project debarred, suspended or otherwise excluded from or ineligible for participation in federal department, agency, assistance programs or activities? Yes No (if Yes, explain in Section B Comments below) Subawards to any entity or individual included in the Federal excluded Parties are prohibited. 7. Ethics in Research Training (applicable to projects funded by NSF) Not applicable because this project is not being funded by NSF. Subrecipient Organization/Institution hereby certifies that it will ensure that all undergraduates, graduate students, and postdoctoral researchers who will be supported by this NSF proposal will be trained on the oversight in the responsible and ethical conduct of research. 8. Facilities and Administrative Rates included in this subaward have been calculated based on: Our federally-negotiated F&A rates for this type of work, or a reduced F&A rate that we hereby agree to accept. (If this box is checked, please attach a copy of your F&A rate agreement must be furnished to UW via hard copy, website, or before a subaward will be issued.) Other rates (please specify the basis on which the rate has been calculated in Section B Comments below) Not applicable (no indirect costs requested for subrecipient) 9. Fringe Benefit Rates included in this subaward have been calculated based on: Rates consistent with or lower than our federally-negotiated rates (If this box is checked, a copy of your FB rate agreement must be furnished to UW before a subaward will be issued.) Other rates (please specify the basis on which the rate has been calculated in Section B Comments below). SECTION B - Comments Page 2 of 5

3 SECTION C Audit Organizations subject to the requirements of OMB Circular A-133 We have completed our A-133 audit for the fiscal year There were no significant deficiencies, material weaknesses, questioned costs, or findings related to any A copy of our A-133 audit report can be found at this website: We have completed our A-133 audit for the fiscal year There were significant deficiencies, material weaknesses, questioned costs, or findings related to any subawards from the University of Washington disclosed. A copy of our A-133 audit report can be found at this website: We have not yet completed our A-133 audit for the fiscal year We expect that the audit report will be completed by. We will send written notification and a copy of the audit report within thirty days of its completion. Organizations NOT subject to the requirements of OMB Circular A please answer both questions 1 & Our organization is not subject to the requirements of OMB Circular A-133 because we: are a U.S. federal government agency are a U.S. Domestic entity that: did not expend $500,000 or more in U.S. federal funds during the latest completed fiscal year are a for-profit organization are a non U.S. based (foreign) entity that: did not expend $500,000 or more in U.S. federal funds during the latest completed fiscal year 2. In lieu of an A-133 audit, we have provided one of the following, if available and/or required per the terms of the subaward from the University of Washington, or when our entity expends more than $500,000 USD in our fiscal year: a general financial or financial statement audit for the fiscal year There were no significant deficiencies, material weaknesses, questioned costs, or findings related to any There were significant deficiencies, material weaknesses, questioned costs, or findings related to any We have not yet completed our financial statement audit for the fiscal year We expect that the audit report will be completed by. We will send written notification and a copy of the audit report within thirty days of its completion. a program-specific audit or an audit meeting the requirements of OMB Circular A-133 on our entity s subaward from UW or on all our entity s US federal expenditures if required per the terms of the subaward from the University of Washington or when our entity expends more than $500,000 USD in US federal funds in our fiscal year. There were no significant deficiencies, material weaknesses, questioned costs, or findings related to any There were significant deficiencies, material weaknesses, questioned costs, or findings related to any We have not yet completed a program-specific audit for the fiscal year We expect that the audit report will be completed by. We will send written notification and a copy of the audit report within thirty days of its completion. Page 3 of 5

4 Organization/company has not been audited by a U.S. Government agency or by an independent public auditing firm for its most recently completed fiscal year ended. SECTION D - For Organizations Not Subject to OMB Circular A General Information The organization has its financial statements reviewed or audited by an independent public accounting firm. The organization represents that it has not been the subject of a for-cause audit or similar investigation, inquiry or review within the last two years by a government agency or independent public accountant. Responsibilities are separated between multiple persons within your organization so that no one individual has complete authority over an entire financial transaction. The organization has effective controls to prevent expenditure of funds in excess of approved, budgeted amount. 2. Cash Management 3. Payroll All cash disbursements within organization are fully documented with evidence of receipt of goods or performance of services. The organization s bank accounts are reconciled monthly. Payroll charges are checked against program budgets. The organization has an effective system to control paid time charged to sponsored agreements. 4. Procurement There are procedures in organization to ensure procurement at competitive prices. 5. Property Management The organization has an effective system for authorization and approval of capital equipment expenditures travel expenditures vendor and subcontractor expenditures The organization requires detailed records of individual capital assets kept and periodically balanced with the general ledger accounts. The organization has effective procedures for authorizing payment and accounting for the disposal of property and equipment. The organization periodically conducts a physical inventory against detailed property records. The organization has written policies concerning capitalization and depreciation. 6. Cost Transfer The organization has a system to ensure that all cost transfers are legitimate and appropriate. 7. Indirect Cost/Fringe Benefits The organization has an indirect cost allocation plan or a negotiated indirect cost rate. Page 4 of 5

5 The organization has a negotiated fringe benefit agreement. Please provide copies of any negotiated indirect cost rate and fringe benefit agreements. The organization does not have a negotiated fringe benefit agreement. Please describe the process for determining how organization will charge the University of Washington indirect costs and fringe benefit expenses at organization s most favorable rates or provide online link: 8. Cost Sharing The organization have an effective system for tracking and determining that it has met any cost sharing goals required for a project. 9. Compliance The organization adopted a written policy of nondiscriminiation and a system for complying with United States federal civil rights requirement. The organization has a cash forecasting process that will minimize the time elapsed between the drawing down of funds and the disbursement of those funds. If organization enters into agreements for work or research to be performed outside of the United States, the organization has systems in place to assure compliance with the Foreign Corrupt Practices Act, including a system to prevent and detect improper payments made to government officials to allow or procure work and research opportunities for or on behalf of organization. APPROVED FOR SUBRECIPIENT The information, certifications and representations above have been read, signed and made by an authorized official of the Subrecipient named herein. The appropriate programmatic and administrative personnel involved in this application are aware of agency policy in regard to subawards and are prepared to establish the necessary inter-institutional agreements consistent with those policies. Any work begun and/or expenses incurred prior to execution of a subaward agreement are at the Subrecipient s own risk. Signature of Subrecipient s Authorized Official Legal Name of Subrecipient s Organization/Institution Name and Title of Authorized Official (Print) Address City, State, Zip Phone Fax Federal Employer Identification Number (EIN) Date DUNS or DUNS+4 number Page 5 of 5