Grant Application Package

Opportunity Title: Offering Agency: CFDA Number: CFDA Description: Opportunity Number: Competition ID: Opportunity Open Date: Opportunity Close Date: Agency Contact: Grant Application Package Reducing Health Disparities Among Minority and Underser National Institutes of Health PA-14-033 FORMS-C 01/05/2014 01/07/2017 era Commons Help Desk Monday to Friday 7 am to 8 pm ET E-mail: helpdesk@od.nih.gov Phone: 1-866-504-9552 All fields that are yellow with a red border or marked with a * are mandatory and must be completed before submission. Filing name can be any name that will help identify the application package after submission thru Grants.gov. This opportunity is only open to organizations, applicants who are submitting grant applications on behalf of a company, state, local or tribal government, academia, or other type of organization. Application Filing Name: John_Doe_NIH_Grant_Application_V1 Select Forms to All mandatory documents Mandatory must be completed. SF424 (R & R) PHS 398 Research Plan PHS 398 Cover Page Supplement Research and Related Senior/Key Person Profile (Expanded) Research And Related Other Project Information Project/Performance Site Location(s) Optional R & R Subaward Budget Attachment(s) Form 5 YR 30 ATT Planned Enrollment Report PHS 398 Cumulative Inclusion Enrollment Report PHS 398 Modular Budget Research & Related Budget Planned Enrollment Report is required if if Human Subjects was marked "yes" on the R&R Other Project Information form. The PHS 398 Modular Budget Box should been checked to enable completion of the modular budget portion of the proposal. Instructions Show Instructions >> This electronic grants application is intended to be used to apply for the specific Federal funding opportunity referenced here. If the Federal funding opportunity listed is not the opportunity for which you want to apply, close this application package by clicking on the "Cancel" button at the top of this screen. You will then need to locate the correct Federal funding opportunity, download its application and then apply.

APPLICATION FOR FEDERAL ASSISTANCE SF 424 (R&R) 3. DATE RECEIVED BY STATE 1. TYPE OF SUBMISSION 4. a. Federal Identifier State Application Identifier OMB Number: 4040-0001 Expiration Date: 6/30/2016 Pre-application Application Changed/Corrected Application b. Agency Routing Identifier 2. DATE SUBMITTED Applicant Identifier 5. APPLICANT INFORMATION Organizational DUNS: Legal Name: Department: University of Illinois Urbana-Champaign Division: Street1: 1901 S. First Street, Suite A City: Champaign County / Parish: State: Country: USA: UNITED STATES ZIP / Postal Code: 61820-7406 Person to be contacted on matters involving this application Prefix: First Name: David Middle Name: W. Last Name: Richardson Position/Title: Street1: City: State: Country: AVCR/Director 1901 S. First Street, Suite A Champaign Phone Number: 217-333-2187 Email: OSP@i u 6. EMPLOYER IDENTIFICATION (EIN) or (TIN): 7. TYPE OF APPLICANT: Other (Specify): Small Business Organization Type 8. TYPE OF APPLICATION: New Resubmission Renewal Continuation Revision USA: UNITED STATES Fax Number: A6 Women Owned County / Parish: Socially and Economically Disadvantaged If Revision, mark appropriate box(es). A. Increase Award B. Decrease Award C. Increase Duration D. Decrease Duration E. Other (specify): c. Previous Grants.gov Tracking ID 041544081 ZIP / Postal Code: 6182-74 6 H: Public/State Controlled Institution of Higher Education te the legal name that should be used for NIH proposals. te the EIN for NIH proposals is slightly different from our standard EIN. Is this application being submitted to other agencies? What other Agencies? 9. NAME OF FEDERAL AGENCY: National Institutes of Health 10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER: TITLE: 11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT: "Title of the Research Project Entered Here" 12. PROPOSED PROJECT: Start Date Ending Date 01/01/2016 12/31/2018 IL-013 13. CONGRESSIONAL DISTRICT OF APPLICANT

SF 424 (R&R) APPLICATION FOR FEDERAL ASSISTANCE Page 2 14. PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION Prefix: First Name: John Middle Name: Last Name: Doe Position/Title: Assistant Professor Organization Name: University of Illinois Urbana-Champaign Department: Chemistry Division: Street1: 234 E. Green Street City: Champaign County / Parish: State: Country: USA: UNITED STATES ZIP / Postal Code: 61820-7124 Phone Number: 555-555-5555 Fax Number: Email: johndoe@illinois.edu 15. ESTIMATED PROJECT FUNDING a. Total Federal Funds Requested b. Total n-federal Funds c. Total Federal & n-federal Funds d. Estimated Program Income 9 0.00 16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER 12372 PROCESS? a. YES THIS PREAPPLICATION/APPLICATION WAS MADE AVAILABLE TO THE STATE EXECUTIVE ORDER 12372 PROCESS FOR REVIEW ON: DATE: b. NO PROGRAM IS NOT COVERED BY E.O. 12372; OR PROGRAM HAS NOT BEEN SELECTED BY STATE FOR REVIEW 17. By signing this application, I certify (1) to the statements contained in the list of certifications* and (2) that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances * and agree to comply with any resulting terms if I accept an award. I am aware that any false, fictitious. or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001) I agree *The list of certifications and assurances, or an Internet site where you may obtain this list, is contained in the announcement or agency specific instructions. 18. SFLLL (Disclosure of Lobbying Activities) or other Explanatory Documentation 19. Authorized Representative Prefix: First Name: Walter Middle Name: K. Last Name: Knorr Position/Title: Organization: Comptroller University of Illinois Urbana-Champaign Department: Street1: 1901 S. First Street, Suite A Division: City: Champaign State: Country: County / Parish: USA: UNITED STATES ZIP / Postal Code: 61820-7406 Phone Number: 217-333-2187 Fax Number: Email: OSP@illinois.edu Signature of Authorized Representative d on submission to Grants.gov Date Signed d on submission to Grants.gov 20. Pre-application 21. Cover Letter Attachment

PHS 398 Research Plan Please attach applicable sections of the research plan, below. OMB Number: 0925-0001 1. Introduction to Application (for RESUBMISSION or REVISION only) 2. Specific Aims Specific_Aims.pdf 3. *Research Strategy 4. Progress Report Publication List Research_Strategy.pdf Human Subjects Sections 5. Protection of Human Subjects Attachments must be provided in all three fields if Human Subjects was marked "yes" on the R&R Other Project Information form. Protection_of_Human_Subject 6. Inclusion of Women and Minorities 7. Inclusion of Children Other Research Plan Sections 8. Vertebrate Animals Inclusion_of_Women_and_Mino Inclusion_of_Children.pdf Attachment required if Vertebrate Animals marked "yes" on R&R Other Project Information form. Vertebrate_Animals.pdf 9. Select Agent Research 10. Multiple PD/PI Leadership Plan 11. Consortium/Contractual Arrangements 12. Letters of Support 13. Resource Sharing Plan(s) Resource_Sharing_Plan.pdf Appendix (if applicable) 14. Appendix s Remove Attachments s Review specific FOA to determine if a Resource Sharing Plan is required. Plans are often required if budget request is over a specified threshold.

PHS 398 Cover Page Supplement OMB Number: 0925-0001 1. Project Director / Principal Investigator (PD/PI) Prefix: *First Name: John Middle Name: *Last Name: Doe 2. Human Subjects Clinical Trial? This section must be completed if Human Subjects was marked "yes" on the R&R Other Project Information Form. *Agency-Defined Phase III Clinical Trial? 3. *Disclosure Permission Statement It is at the PI's discretion to allow disclosure. If this application does not result in an award, is the Government permitted to disclose the title of your proposed project, and the name, address, telephone number and e-mail address of the official signing for the applicant organization, to organizations that may be interested in contacting you for further information (e.g., possible collaborations, investment)? 4. *Program Income *Is program income anticipated during the periods for which the grant support is requested? If you checked "yes" above (indicating that program income is anticipated), then use the format below to reflect the amount and source(s). Otherwise, leave this section blank. *Budget Period *Anticipated Amount ($) *Source(s)

PHS 398 Cover Page Supplement 5. Human Embryonic Stem Cells *Does the proposed project involve human embryonic stem cells? If the proposed project involves human embryonic stem cells, list below the registration number of the specific cell line(s) from the following list: http://stemcells.nih.gov/research/registry/. Or, if a specific stem cell line cannot be referenced at this time, please check the box indicating that one from the registry will be used: Cell Line(s): Specific stem cell line cannot be referenced at this time. One from the registry will be used. 6. Inventions and Patents (For renewal applications only) *Inventions and Patents: If the answer is "" then please answer the following: *Previously Reported: 7. Change of Investigator / Change of Institution Questions Change of principal investigator / program director Name of former principal investigator / program director: Prefix: *First Name: Middle Name: *Last Name: Change of Grantee Institution *Name of former institution:

RESEARCH & RELATED Senior/Key Person Profile (Expanded) OMB Number: 4040-0001 Expiration Date: 6/30/2016 PROFILE - Project Director/Principal Investigator Prefix: * First Name: John Middle Name: * Last Name: Doe Position/Title: Assistant Professor Department: Chemistry Organization Name: University of Illinois Urbana-Champaign Division: * Street1: 234 E. Green Street * City: Champaign County/ Parish: * State: * Country: USA: UNITED STATES * Zip / Postal Code: 61820-7124 * Phone Number: 555-555-5555 Fax Number: * E-Mail: johndoe@illinois.edu Credential, e.g., agency login: JOHN_DOE * Project Role: PD/PI Other Project Role Category: Commons ID must be listed for all personnel in the PD/PI role. Degree Type: Degree Year: PhD 2001 *Attach Biographical Sketch Attach Current & Pending Support Biosketch.pdf PROFILE - Senior/Key Person 1 Prefix: * First Name: Jane Middle Name: * Last Name: Smith Position/Title: Professor Organization Name: University of Illinois Urbana-Champaign * Street1: 100 Green St. Department: Chemistry Division: This field is required by NIH, even though it is not marked as mandatory. * City: Champaign County/ Parish: * State: * Country: USA: UNITED STATES * Zip / Postal Code: 61820-1234 * Phone Number: 444-444-4444 Fax Number: * E-Mail: janesmith@illinois.edu Credential, e.g., agency login: JANE_SMITH * Project Role: Co-Investigator Other Project Role Category: Degree Type: Degree Year: Attach Biographical Sketch Attach Current & Pending Support Co-Investigator should be used in place of Co-PI. Biosketch.pdf Delete Entry Next Person To ensure proper performance of this form; after adding 20 additional Senior/ Key Persons; please save your application, close the Adobe Reader, and reopen it.

RESEARCH & RELATED Other Project Information OMB Number: 4040-0001 Expiration Date: 6/30/2016 1. Are Human Subjects Involved? 1.a. If YES to Human Subjects Is the Project Exempt from Federal regulations? If yes, check appropriate exemption number. 1 2 3 4 5 6 If no, is the IRB review Pending? IRB Approval Date: Human Subject Assurance Number: 4 2. Are Vertebrate Animals Used? 2.a. If YES to Vertebrate Animals Is the IACUC review Pending? Human Subjects and Vertebrate Animals are project specific. If marked "yes", additional materials are needed on the PHS 398 Research Plan page. IACUC Approval Date: Animal Welfare Assurance Number: A3118-01 3. Is proprietary/privileged information included in the application? 4.a. Does this Project Have an Actual or Potential Impact - positive or negative - on the environment? 4.b. If yes, please explain: 4.c. If this project has an actual or potential impact on the environment, has an exemption been authorized or an environmental assessment (EA) or environmental impact statement (EIS) been performed? 4.d. If yes, please explain: 5. Is the research performance site designated, or eligible to be designated, as a historic place? 5.a. If yes, please explain: 6. Does this project involve activities outside of the United States or partnerships with international collaborators? 6.a. If yes, identify countries: 6.b. Optional Explanation: The Summary should be no more than 30 lines of text and the Narrative should only be 2-3 sentences. 7. Project Summary/Abstract Summary.pdf 8. Project Narrative Narrative.pdf 9. Bibliography & References Cited References.pdf 10. Facilities & Other Resources Facilities.pdf 11. Equipment Equipment.pdf 12. Other Attachments s s s All attachments must be in PDF format. Review specific RFP to determine if additional attachments are required beyond those listed here.

Project/Performance Site Location(s) OMB Number: 4040-0010 Expiration Date: 9/30/2016 Project/Performance Site Primary Location Organization Name: DUNS Number: * Street1: * State: * Country: USA: UNITED STATES I am submitting an application as an individual, and not on behalf of a company, state, local or tribal government, academia, or other type of organization. University of Illinois Urbana-Champaign 0415440810000 506 S. Wright Street * City: Urbana County: Champaign Although this field is not marked as mandatory, it is a required field for NIH. This address should always be used for the Performance Site. * ZIP / Postal Code: 61801-3602 * Project/ Performance Site Congressional District: IL-013 Project/Performance Site Location Organization Name: 1 I am submitting an application as an individual, and not on behalf of a company, state, local or tribal government, academia, or other type of organization. DUNS Number: * Street1: * City: County: * State: * Country: USA: UNITED STATES * ZIP / Postal Code: * Project/ Performance Site Congressional District: Additional Location(s)

Modular budgets do not require detailed breakdown of direct costs. Only direct PHS 398 Modular Budget costs, consortium F&A (if applicable), and indirect costs are listed. OMB Number: 0925-0001 Budget Period: 1 Start Date: 01/01/2016 End Date: 12/31/2016 A. Direct Costs With Modular budgets, direct costs (less consortium F&A) must be in modules of $25,000. Direct Cost less Consortium F&A Consortium F&A Total Direct Costs Funds Requested ($) 125,000.00 125,000.00 B. s 1. Type Rate (%) Base ($) Funds Requested ($) MTDC 58.60 111,360.00 65,257.00 2. 3. 4. Cognizant Agency (Agency Name, POC Name and Phone Number) ONR, Beth Snyder, 70-696-5755 Rate Agreement Date 07/01/2015 Total s 65,257.00 C. Total Direct and s (A + B) Funds Requested ($) 190,257.00 A. Direct Costs Budget Period: 2 Start Date: 01/01/17 End Date: 12/31/17 Direct Cost less Consortium F&A Consortium F&A Total Direct Costs Funds Requested ($) 125,000.00 125,000.00 B. s 1. Type Rate (%) Base ($) Funds Requested ($) MTDC 58.60 110,950.00 65,017.00 2. 3. 4. Cognizant Agency (Agency Name, POC Name and Phone Number) ONR, Beth Snyder, 70-696-5755 Rate Agreement Date 07/01/2015 Total s 65,017.00 C. Total Direct and s (A + B) Funds Requested ($) 190,017.00

PHS 398 Modular Budget Budget Period: 3 A. Direct Costs Start Date: 01/01/18 End Date: 12/31/18 Direct Cost less Consortium F&A Consortium F&A Total Direct Costs Funds Requested ($) 75,000.00 75,000.00 B. s 1. Type Rate (%) Base ($) Funds Requested ($) MTDC 58.60 71,523.00 41,912.00 2. 3. 4. Cognizant Agency (Agency Name, POC Name and Phone Number) ONR, Beth Snyder, 70-696-5755 Rate Agreement Date 07/01/2015 Total s 41,912.00 C. Total Direct and s (A + B) Funds Requested ($) 116,912.00 Cumulative Budget Information 1. Total Costs, Entire Project Period Section A, Total Direct Cost less Consortium F&A for Entire Project Period $ 325,000.00 Section A, Total Consortium F&A for Entire Project Period $ Section A, Total Direct Costs for Entire Project Period $ Section B, Total s for Entire Project Period $ 325,000.00 172,186.00 Section C, Total Direct and s (A+B) for Entire Project Period $ 2. Budget Justifications 497,186.00 Modular budgets that request a consistent number of modules over the period of performance ($25,000 increments) only need to provide a personnel justification. Personnel Justification Consortium Justification Budget_Justification.pdf Additional Narrative Justification Additional_Narrative_Justifica The consortium/subaward's budget should be included if applicable. If a varying number of modules is requested from one year to the next (e.g., $125,000 in Year 1 and $150,000 in Year 2) then an additional justification is needed to explain the need for varying modules.