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JHU SCHOOL OF MEDICINE SUBAWARD & SUBCONTRACT INFORMATION SHEET

Please submit completed sub infosheets (in WORD), the signature page (PDF), and other required documents to ORASUBCONTRACTS@jhmi.edu.

JHU Contact Information

Department: Medicine – Infectious Diseases

JHU Principal Investigator

Name (need credentials): George Washington

Address /Suite: 1550 Orleans St, Rm 100

City, State, Zip Baltimore, MD 21287

Phone Number: 410-955-3507

E-mail Address: gwash1@jhmi.edu

Responsible Cost Center: 1704612501

JHU Departmental Contact for Study Questions

Name: Katherine Newkirk

Address/Suite: 1830 E. Monument St

City, State, Zip Baltimore, MD 21287

Phone Number: 410-614-0923

E-mail Address: kbnewkirk@jhmi.edu

JHU Contact for Invoicing/Reports/Goods Receipts

Name: Katherine Newkirk

Address/Suite:1830 E. Monument St

City, State, Zip Baltimore, MD 21287

Phone Number: 410-614-0923

E-mail Address: kbnewkirk@jhmi.edu

JHED ID/SAP ID: kbarlow2

Additional JHU Contacts to receive FE

Name: Name:

Name: Name:

Subsite Contact Information

Subsite Legal Name: KwaZulu Natal Research Institute for HIV and Tuberculosis

Subsite Principal Investigator

Name (need credentials): Martha Washington

Phone Number: +078 390 2541, +031 260 4073

E-mail Address: Martha.Washington@k-rith.org

Subsite Research Administration Office Contact

Name: John Adams, Research Grants Officer

Address: Nelson R. Mandela School of Medicine,

University of KwaZulu-Natal

K-RITH Tower Bldg, Lvl 3

Private Bag X7, Congella 4013

South Africa

Phone Number: +27 31 260 4113

E-mail Address: John.Adams@k-rith.org

Subsite Payment Remittance Address

Dept/Building name, Suite: Nelson R. Mandela School of Medicine, University of KwaZulu-Natal

K-RITH Tower Bldg, Lvl 3

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Street Address: Private Bag X7, Congella 4013

City, State, zip: South Africa

Prime Award Information

Grantor Name: Doris Duke Charitable Foundation Sponsor Award Number: 6778-13 Prime Award Current Budget Period: 01/01/14-12/31/14

SAP Grant #:112233

COEUS IPN #: 12053164

IO # (900#):90001234

Additional Details

A. FINANCIAL

1. Subsite New Budget Period: 03/01/13-12/31/14

2. For the new budget period, how much will JHU pay the subsite (subsite direct costs + subsite indirect costs, not including any carryover $)? $0, it’s a NCE

3. Does this subaward include any funding carried over from a previous budget year? Yes

a. If the answer is yes, do not include carryover $ on the budget form

b. If the answer is yes, how much? $71,084.63

c. $ is being carried over from what year (mm/dd/yyyy)? 03/01/12-02/28/13

d. $ is being carried over into what year (mm/dd/yyyy)? 03/01/13-12/31/14

4. Is the IO# given in the Prime Award Information an allocation account? No

a. If so, please provide the Master account#. 90001234

5. Are there other subs to this subsite under this grant? no

6. Will the site get any start-up funds upon execution of the subagreement? n/a

If the answer is yes, how much?

B. REGULATORY

1. Please provide the site’s DUNS number. 637360244

2. Will the work under this subagreement involve human subjects? no

3. Will there be disclosure to the subsite of individually identifiable health information? no

4. Will the work under the sub involve vertebrate animal research? no

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C. STUDY-RELATED

1. What performance milestones or deliverables (i.e. reports, samples, patient data) is the site expected to deliver?

COMPLETE THE TABLE BELOW: (MANDATORY FOR YEAR 1, COMPETING RENEWALS, REVISED SOW’S!!)

DELIVERABLE DUE DATE OR TIME FRAME EXPECTED

N/A (NCE)

2. Will the subsite be conducting a clinical trial? no

If the answer is yes, please answer the following:

a. Is the protocol investigator initiated?

b. How many total patients is the site expected to recruit?

c. If patient total is unknown, is there an enrollment 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 amount? If yes, how much?

f. Will the site be paid any fixed costs? If yes, how much?

g. Will the site be paid for a patient’s partial completion of the trial? How much?

h. Is payment contingent upon submission of case report forms or other data?

i. If yes, will the site still have to submit invoices?

j. Does the site submit CRF’s before / at the same time as invoices?

k. Will the site be required to submit any other technical reports, financial reports, and/or final reports?

l. If yes, what are they? , when are they due?

3. Is a study drug being supplied to the subsite? no

If the answer is yes, please answer the following:

a. Where it is from?

b. Does JHU have an agreement with the Pharmaceutical company?

c. Will JHU send it to the subsite or will it be sent by the other entity (i.e. a pharmaceutical company)?

4. Will any other physical materials (i.e. cells, samples, etc.) be shipped to the subsite by JHU? no

a. Were the materials generated/invented/created by JHU as a result of this study/project?

b. What are the materials?

5. Is any equipment being supplied/sent to the subsite? no

If the answer is yes, please answer the following:

a. Where it is from?

b. Who will own it?

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c. If not owned by the site, are there plans for the owner to remove it from the site?

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Required Attachments

Significant Financial Interest Form (“SFI” for Federal Prime Awards) The subsite should complete and return the SFI to the dept if a Subrecipient Commitment Form (“SCF”) was not completed at the time of JHU application. The dept may submit the SCF if it was completed at time of application instead of the SFI when submitting all the required paperwork to the Subawards team. The SFI/SCF is only required for Subawards under Federal Prime Awards.

Statement of Work (“SOW”)

The SOW will serve as the gauge to determine whether the subsite adequately performs the work under the sub. This document should provide a concise explanation of the purpose of the work to be performed by the subsite, as well as a description of what JHU will be paying for. For example, if the subsite is supposed to submit data, samples, etc. to JHU, the SOW should state that fact. If the site is participating in a clinical trial, the SOW should state how many patients the site is expected to recruit, and what data and/or case report forms the subsite must submit to JHU in order to be paid. All deliverables expected from the subsite should be included in the SOW. Please bear in mind that the SOW should be in terms understandable to the lay person and must be more detailed than a general description of the whole project.

Budget

Please provide a budget for the subsite. The budget should include the name of the subsite, the sub-PI, dates, and

the titles (and preferably the names) of any other personnel who will be receiving salary support. If the budget

includes funding for “Supplies” or “Other Expenses”, it should provide a breakdown of any such funding exceeding

$1,000. Any travel costs should also be explained.

IRB/IACUC Approval (if applicable)

If the sub-PI will be working with Vertebrate Animals and/or conducting human subjects research, please provide a copy of the subsite’s IRB and/or IACUC approval. The expiration date for the approval(s) must fall within or after the current budget year. If the sub site does not have an IRB committee, the sub-PI should be added to the JHU PI’s e-IRB protocol, and proof of addition with JHU approval number and expiration date should be provided.

Wire Transfer Authorization

A Wire Transfer Authorization form is necessary for the Purchasing department to set up purchase orders for foreign

sites. The subsite should fill out the top section. The WTA is only required for the Original Subaward to a foreign

site, or if the WTA information changes at the time of a modification.

By signing this form, I acknowledge that JHU will enter into a subaward/subcontract for which I will be responsible, and that sponsored

funding awarded to JHU for my research will be used to pay the costs of the subaward/subcontract. In addition, I have reviewed and

approved the Statement of Work and Budget submitted as attachments to this form.

JHU Principal Investigator

Dr. George Washington

Printed Name Signature Date

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ORA USE ONLY

Info from Dept Received:

Sub Type:

Vendor #:

96# Requested:

Sub IO #-

SC Requested/PO rev:

JHU PO #:

Cumulative Total of Sub/PO:

IRB Expiration Date: ; Exempt:

IACUC Expiration Date:

Sub Drafted:

Sub E-Mailed:

Executed Sub Received:

Executed to Dept.: