Populate this Grants.gov System to System (s2s) form by answering the Questionnaire  “PHS 398 Cover Page Supplement V 3-0” and entering Project Income in the budget, if appropriate.

This questionnaire will appear in your proposal when you link a Grants.gov opportunity that utilizes this version of the form. 

NIH will require this 3.0 version in their "forms D" opportunities for submissions after May 25, 2016.


The "Grants.gov S2S" Questionnaire will also appear and require answers to support other forms in the opportunity.

 

 

Form Location 

Kuali Screen

Field

Instructions

 

 

Burden Statement:

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0001).  Do not return the completed form to this address.

 

Clinical Trial


PHS Cover Page Supplement 3-0


 

 

Question

Select an answer: Yes or No to indicate whether the project is a clinical trial.

Agency-Defined Phase III Clinical Trial? 


PHS Cover Page Supplement 3-0


 Question


Select an answer: Yes or No

Check "yes" or "no" to indicate whether the project includes an agency-defined phase III clinical trial. See Application Guide for the specific definition.

 

Will vertebrate animals be used in this project?


PHS Cover Page Supplement 3-0


 

Question

Select an answer: Yes or No to indicate whether vertebrate animals will be used.

Are Vertebrate animals euthanized?


PHS Cover Page Supplement 3-0


 

Question

Select an answer: Yes or No.

You must answer the Animals Euthanized question if you checked "Yes" for the “Are Vertebrate Animals Used?” question. Check "Yes" if animals in your project are euthanized. See agency-specific instructions for additional information

Is the method consistent with American Veterinary Medical Association (AVMA) guidelines?


PHS Cover Page Supplement 3-0

 

 

Question

Select an answer: Yes or No.

You must answer the Euthanized Method Consistent with AVMA question if you checked "Yes" for the “Are animals euthanized?” question. Check "Yes" if method of euthanasia is consistent with the American Veterinary Medical Association Guidelines for the Euthanasia of Animals. See agency-specific instructions for additional information.

If NO, to AVMA guidelines, describe the method and provide scientific justification in 1000 characters or less.


PHS Cover Page Supplement 3-0


 

Question

Enter your text: the description must be 1000 characters or less.

If you answered “No” to the question “Is method consistent with AVMA Guidelines?” you must describe the method of euthanasia and provide a scientific justification for its use.


 

Program Income

Budget:

Commitments > Project Income

Enter Income and Description for each project period where income is expected.

If the application is funded, the Notice of Grant Award will provide specific instructions regarding the use of such income.

 

Human Embryonic
Stem Cells


PHS Cover Page Supplement 3-0


 

Question

Select an answer: Yes or No.
Does the proposed project involve human embryonic stem cells?

A Yes response will present additional questions.

Can a Specific
Stem Cell line(s)
be referenced?


PHS Cover Page Supplement 3-0

 


 

Question

Select an answer: Yes or No. Can a specific stem cell line be referenced at this time? If stem cells will be used, but a specific line cannot be referenced at the time of application submission, answer NO, and include a statement in your narratives that one from the registry will be used.

List the specific 

PHS Cover Page Supplement 3-0

 

 

Question

Enter one 4 digit value in each field.

List the 4-digit registration number of the specific cell line(s) from the NIH stem cell registry found at: http://grants.nih.gov/stem_cells/registry/current.htm

This form can submit up to 200 registration numbers of the cell lines. This questionnaire initially presents 20 fields if the answer to the previous question is Yes. Click the “More answers…” hyperlink below the last cell entry field to generate 20 more fields.

 

Is this a Renewal application


PHS Cover Page Supplement 3-0


 

Question

Select an answer: Yes or No. If Yes, additional questions will be presented.

Inventions and Patents

(reporting information required for Renewal applications)


PHS Cover Page Supplement 3-0


 

Question

Select an answer:
Check "No" if no inventions were conceived or reduced to practice during the course of work under this project. 

Check "Yes" if any inventions were conceived or reduced to practice during the previous period of support

If "Yes" (inventions were conceived or reduced to practice)  


PHS Cover Page Supplement 3-0


 

Question

Select an answer: Yes or No as to whether this information has been reported previously to the PHS or to the applicant organization official responsible for patent matters.


Change of Investigator

Does this application reflect a change in principal investigator/program director from that indicated on a previous application?


PHS Cover Page Supplement 3-0

 

 

Question

Select an answer: Yes or No.

 


If Yes, Select the PI


PHS Cover Page Supplement 3-0


 

Question

Search the Address Book to find the Investigator.

Change of Institution

Has the grantee institution changed with this application?


PHS Cover Page Supplement 3-0


 

Question

Select an answer: Yes or No.

 


If Yes, select the Institution


PHS Cover Page Supplement 3-0


 

Question

Search the Address book and select the former Institution (the Organization from address book record will be used).