RESEARCH FOUNDATION of The City University of New York 230 West 41st Street New York, NY 10036-7207

Rev. 11.20.2018

CONTRACT INTAKE FORM This request is for review and execution of the following (Please Select Only One): ☐ New Agreement ☐ Amendment to Log Number ______________________

☐ Interagency Agreement(If this box is checked DO NOT complete this form. The CUNY Office of General Counsel reviews/negotiates this type of agreement. Send Agreement to: OGC@cuny.edu)

☐ Material Transfer Agreement (MTA)If the MTA box is checked please answer the following (RF may send the agreement to CUNY for review and signature)

Is this request for an RF-administered sponsored program? ☐ Yes ☐ No If Yes, provide college account/PRSY _________________________ What is the Fee? ____________________________ (enter 0 if there is no fee)

College Principal Investigator (PI) _____________________________________________

Title of Project: _______________________________________________________________________________________________________________

Date Contract Received _____________________ Date Submitted to RF _____________________ Amount _____________________

Sponsor Name ______________________________________________ Sponsor Contact _______________________________________

Sponsor Contact Phone Number: ____________________________ Sponsor Contact Email _________________________________

Is this a New York Sponsor? ☐ Yes ☐ No* * If No - The RF cannot advise on, interpret or apply Non-New York law. In the event of a dispute, there may be costly legal or litigation expenses for which the College will be responsible. By completing this form, the College acknowledges that it understands and accepts those risks and that it wants the RF to administer the project.

Is the Research Foundation named as a party to the agreement? ☐ Yes ☐ No**

Does the contract contain the Research Foundation’s address? ☐ Yes ☐ No** **If No to either question, the College should request Sponsor to make the needed change and then resubmit this request. If the Sponsor declined the College’s request to make the needed change, what reason was given?

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Has each Investigator filed a Conflict of Interest disclosure form as required by CUNY Policy and CUNY Procedures?☐Yes ☐No*** ***If No - Please file prior to submission of your contract.

Has a determination or management plan been issued? ☐ Yes ☐ No If Yes, attach a copy

If No, please explain: ____________________________________________________________________________________________ ________________________________________________________________________________________________________________

IRB / IACUC Documentation of the necessary IRB and/or IACUC approval must be included if the scope of work involves research with human or animal subjects. Is an IRB/IACUC letter included with this submission? ☐ Yes, the IRB and/or IACUC letter(s) is/are included.☐ No. Human or animal subjects will not be used.☐ No. IRB/IACUC approval is pending, and the IRB/IACUC determination will be submitted once received.******** Submission of this form constitutes a certification that no human or animal subjects research will be commenced until an IRB/IACUC determination is in place.

Where indicated, the following documents must be attached for this agreement to be processed: ☐ Scope of Work (SOW should not include proprietary or confidential information.)

(For amendments, attach a new Scope if there is one. If Scope is unchanged, check here ☐)☐ Budget (for amendments, attach a new Budget if there is one. If Budget is unchanged, check here ☐)☐ Proposal (if the agreement references or incorporates the proposal)☐ Completed Attachment 3B (for Federal FDP awards)College AuthorizationBy signing below, I acknowledge that the Research Foundation Administration Fees will be charged to the college and, I authorize the Research Foundation of CUNY to execute the attached Agreement on behalf of:

Name ________________________________________

Signed __________________________________ Date __________________________ Title __________________________________________________________ Phone No. ___________________________

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