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Supplement
COVER SHEET FOR PROPOSAL TO THE NATIONAL SCIENCE FOUNDATIO N
PROGRAM ANNOUNCEMENT/SOLICITATION NO ./CLOSING DATE/it not in response to a program announcement/solicitation enter NSF 04-23
FOR NSF USE ONLY
NSF PROPOSAL NUMBER
FOR CONSIDERATION BY NSF ORGANIZATION UNIT(S)
(Indicate the most specific unit known, I .e. program, division, etc.)
REC - PROGRAM EVALUATIO N
DATE RECEIVED
NUMBER OF COPIES
DIVISION ASSIGNED FUND CODE
D UNS# (Data Universal Numberingsystem)
FILE LOCATIO N
872612445
EMPLOYER IDENTIFICATION NUMBER (EIN) O R
TAXPAYER IDENTIFICATION NUMBER (TIN)
SHOW PREVIOUS AWARD NO, IF THIS I S
❑ A RENEWAL
❑ AN ACCOMPLISHMENT-BASED RENEWA L
IS THIS PROPOSAL BEING SUBMITTED TO ANOTHER FEDERA L
AGENCY?
YES ❑ NO ❑ IF YES, LIST ACRONYM(S )
0535492
NAME OF ORGANIZATION TO WHICH AWARD SHOULD BE MADE
ADDRESS OF AWARDEE ORGANIZATION, INCLUDING 9 DIGIT ZIP COD E
Cornell University - Stat e
S p onsored Pro grams Service s
Ithaca, NY. 14853280 1
Cornell University - State
AWARDEE ORGANIZATION CODE (IF KNOWN)
002711000 1
NAME OF PERFORMING ORGANIZATION, IF DIFFERENT FROM ABOVE
ADDRESS OF PERFORMING ORGANIZATION, IF DIFFERENT, INCLUDING 9 DIGIT ZIP COD E
PERFORMING ORGANIZATION CODE (IF KNOWN )
IS AWARDEE ORGANIZATION (Check All That Apply)
❑ SMALL BUSINESS
(See GPG II.0 For Definitions)
❑ FOR-PROFIT ORGANIZATION
TITLE OF PROPOSED PROJECT Building Evaluation System Capacity for
❑ MINORITY BUSINES S
❑ IF THIS IS A PRELIMINARY PROPOSA L
❑ WOMAN-OWNED BUSINESS THEN CHECK HER E
STEM Programs : Enhancin g
Capability and Advancing Practic e
REQUESTED AMOUN T
$
PROPOSED DURATION (1-60 MONTHS)
33,000
REQUESTED STARTING DATE
0 months
SHOW RELATED PRELIMINARY PROPOSAL NO .
IF APPLICABL E
CHECK APPROPRIATE BOX(ES) IF THIS PROPOSAL INCLUDES ANY OF THE ITEMS LISTED BELOW
❑ HUMAN SUBJECTS (GP G II .D .6)
❑ BEGINNING INVESTIGATOR (GPG I .A)
❑ DISCLOSURE OF LOBBYING ACTIVITIES (GPG II .C)
Exemption Subsectio n
or IRB App . Date
❑ PROPRIETARY & PRIVILEGED INFORMATION (GPG I .B, II .C .1 .d )
❑ INTERNATIONAL COOPERATIV E ACTIVITIES : COUNTRY/COUNTRIES INVOLVED
❑ HISTORIC PLACES (GPG II .C .2.j)
(GPG II .C .2.j)
❑ SMALL GRANT FOR EXPLOR . RESEARCH (SGER) (GPG II .D .1)
❑ VERTEBRATE ANIMALS (GPG 11 .D.5) IACUC App. Date
PI/PD DEPARTMENT
PI/PD POSTAL ADDRES S
Policy Analysis & Management Dept.
PI/PD FA NUMBE R
607
X FAX
NAMES (TYPED)
❑ HIGH RESOLUTION GRAPHICS/OTHER GRAPHICS WHERE EXACT COLO R
REPRESENTATION I S REQUIRED FOR PROPER INTERPRETATION (GPG I .G .1 )
249 MVR
Cornell University
Ithaca, NY 148532801
United States
High Degree
Yr of Degree
Telephone Number
PhD
1980
607-255-0887
Electronic Mail Addres s
PI/PD NAME
William M Trochim
CO-PI/PD
CO-PI/P D
CO-PI/P D
CO-PI/PD
Page 1 of 2
w [email protected]
CERTIFICATION PAG E
Certification for Authorized Organizational Representative or Individual Applicant :
By signing and submitting this proposal, the individual applicant or the authorized official of the applicant institution is : (1) certifying that
statements made herein are true and complete to the best of his/her knowledge ; and (2) agreeing to accept the obligation to comply with NS F
award terms and conditions if an award is made as a result of this application . Further, the applicant is hereby providing certification s
regarding debarment and suspension, drug-free workplace, and lobbying activities (see below), as set forth in Gran t
Proposal Guide (GPG), NSF 04-23 . Willful provision of false information in this application and its supporting documents or in reports required
under an ensuing award is a criminal offense (U . S . Code, Title 18, Section 1001) .
In addition, if the applicant institution employs more than fifty persons, the authorized official of the applicant institution is certifying that the institution ha s
implemented a written and enforced conflict of interest policy that is consistent with the provisions of Grant Policy Manual Section 510 ; that to the best
of his/her knowledge, all financial disclosures required by that conflict of interest policy have been made ; and that all identified conflicts of interest will hav e
been satisfactorily managed, reduced or eliminated prior to the institution's expenditure of any funds under the award, in accordance with th e
institution's conflict of interest policy . Conflicts which cannot be satisfactorily managed, reduced or eliminated must be disclosed to NSF .
Drug Free Work Place Certification
By electronically signing the NSF Proposal Cover Sheet, the Authorized Organizational Representative or Individual Applicant is providing the Drug Free Work Place Certificatio n
contained in Appendix C of the Grant Proposal Guide .
Debarment and Suspension Certification
(If answer "yes", please provide explanation .)
Is the organization or its principals presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily exclude d
from covered transactions by any Federal department or agency?
Yes ❑
No ❑
By electronically signing the NSF Proposal Cover Sheet, the Authorized Organizational Representative or Individual Applicant is providing the Debarment and Suspension Certificatio n
contained in Appendix D of the Grant Proposal Guide .
Certification Regarding Lobbyin g
This certification is required for an award of a Federal contract, grant, or cooperative agreement exceeding $100,000 and for an award of a Federal loan o r
a commitment providing for the United States to insure or guarantee a loan exceeding $150,000 .
Certification for Contracts, Grants, Loans and . Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that :
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influenc e
an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connectio n
with the awarding of any federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement ,
and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement .
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer o r
employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with thi s
Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure of Lobbyin g
Activities," in accordance with its instructions .
(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers includin g
subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements and that all subrecipients shall certify and disclose accordingly .
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into . Submission of this
certification is a prerequisite for making or entering into this transaction imposed by section 1352, Title 31, U .S. Code . Any person who fails to file th e
required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure .
AUTHORIZED ORGANIZATIONAL REPRESENTATIVE
NAM E
TELEPHONE NUMBER
SIGNATURE
ELECTRONIC MAIL ADDRESS
DAT E
FAX NUMBE R
*SUBMISSION OF SOCIAL SECURITY NUMBERS IS VOLUNTARY AND WILL NOT AFFECT THE ORGANIZATION'S ELIGIBILITY FOR AN AWARD . HOWEVER, THEY ARE A N
INTEGRAL PART OF THE INFORMATION SYSTEM AND ASSIST IN PROCESSING THE PROPOSAL . SSN SOLICITED UNDER NSF ACT OF 1950, AS AMENDED .
Page 2 of 2
SUMMARY OF PROPOSED WOR K
Funding for two undergraduate students is requested as a supplemental grant to existin g
NSF reward #0535492 . Two students, Sabrina Rahman and Anna Hays, have been pre-selecte d
for these positions (see biographical sketches in supplemental documents) . Both researc h
assistants will primarily be responsible for assisting with tasks related to th e
development of both a Theory of Systems Evaluation and the corresponding protoco l
described fully in the "Building Evaluation Systems Capacity for STEM Programs" projec t
funded in October 2005 . In particular, the research assistants will be expected t o
conduct library research and literature reviews, assist in the identification and/o r
development of indicator variables and measures of outcomes, keep comprehensive an d
accurate records for the project, and assist in the production of reports and papers .
JUSTIFICATION FOR SUPPLEMENTAL FUNDING .
Ms. Rahman and Ms . Hays have a history of working with the project's Principa l
Investigator (Bill Trochim) and research team on this important evaluation project .
Furthermore, both the PI and the members of the research team share a commitment to engag e
undergraduates in research projects related to a variety of programmatic areas includin g
systems evaluation . In particular, both Ms . Rahman and Ms . Hays have successfully
completed similar work in relation to a project aimed at improving the evaluation capacit y
and evaluation systems in extension and outreach throughout New York State . Thes e
research assistants have already completed extensive literature reviews and assisted wit h
composing reports related to a variety of program areas including health and nutrition ,
family and youth development, community development, and STEM education .
Finally, please note that both Ms . Rahman and Ms . Hays were selected from a large pool o f
applicants interested in this research opportunity because they both expressed a
particular interest in evaluation, have experience in conducting extensive literatur e
reviews, and have strong academic records .
SUMMARY
YEAR
PROPOSAL BUDGET
1
FOR NSF USE ONLY
PROPOSAL NO .
DURATION (months )
ORGANIZATION
Cornell University - State
Proposed
PRINCIPAL INVESTIGATOR / PROJECT DIRECTOR
Grante d
AWARD NO .
William M Trochi m
A . SENIOR PERSONNEL: PI/PD, Co-PI's, Faculty and Other Senior Associate s
( List each se Paratel Y with title, A.7. show number in bracket s)
1.
William M Trochim - none
Fund s
R equeste d B y
proposer
=ésônmônlhs
CAL
ACAD
SUM R
Fund s
gran t e d b y NS F
(if different )
0 .00
0 .00
0 .00 $
0 $
0 .00
0 .00
0 .00
0
0 .00
0 .00 __- 0 .00
0
0 .001
0 .00
0.00
0.00
0
2.
3.
4.
5.
6. (
0 ) OTHERS (LIST INDIVIDUALLY ON BUDGET JUSTIFICATION PAGE)
7. ( 1 ) TOTAL SENIOR PERSONNEL (1 -6)
B . OTHER PERSONNEL (SHOW NUMBERS IN BRACKETS )
1. (
0)
2. (
POST DOCTORAL ASSOCIATES
0 ) OTHER PROFESSIONALS (TECHNICIAN, PROGRAMMER, ETC .)
3. (
0)
4 .(
5. (
GRADUATE STUDENTS
0) UNDERGRADUATE STUDENTS
0 ) SECRETARIAL - CLERICAL (IF CHARGED DIRECTLY)
6. (
0)
0 .00
0 .00
0
0
0
0
0
OTHER
TOTAL SALARIES AND WAGES (A + B)
0
0
C. FRINGE BENEFITS (IF CHARGED AS DIRECT COSTS)
_ TOTAL SALARIES, WAGES AND FRINGE BENEFITS (A + B + C)
Q
D . EQUIPMENT (LIST ITEM AND DOLLAR AMOUNT FOR EACH ITEM EXCEEDING $5,000 . )
1 . DOMESTIC (INCL. CANADA, MEXICO AND U .S . POSSESSIONS)
0
0
2. FOREIGN
Q
TOTAL EQUIPMENT
E . TRAVEL
F . PARTICIPANT SUPPORT COST S
1 . STIPENDS
$
20,800
0
0
0
2. TRAVEL
3. SUBSISTENCE
4 . OTHER
TOTAL NUMBER OF PARTICIPANTS
(
i
I
2)
TOTAL PARTICIPANT COSTS
20, °D O
G . OTHER DIRECT COSTS
1 . MATERIALS AND SUPPLIES
2 . PUBLICATION COSTS/DOCUMENTATION/DISSEMINATION
0
0
3 . CONSULTANT SERVICES
Q
0
0
0
0
20 .80 0
4 . COMPUTER SERVICES
5. SUBAWARDS
6. OTHER
TOTAL OTHER DIRECT COSTS
H . TOTAL DIRECT COSTS (A THROUGH G)
I . INDIRECT. COSTS (F&A)(SPECIFY RATE AND BASE )
administrative allowance (Rate : 25 .0000, Base : 20800)
TOTAL INDIRECT COSTS (F&A )
J . TOTAL DIRECT AND INDIRECT COSTS (H + I)
K . RESIDUAL FUNDS (IF FOR FURTHER SUPPORT OF CURRENT PROJECTS SEE GPG II .C .6.j .)
$
L . AMOUNT OF THIS REQUEST (J) OR (J MINUS K)
M . COST SHARING PROPOSED LEVEL
$
0
AGREED LEVEL IF DIFFERENT $
PI/PD NAM E
William M Trochim
ORG. REP . NAME*
5,20 0
26,00 0
0
26,000 $
FOR NSF USE ONLY
INDIRECT COST RATE VERIFICATIO N
Date Checked
Date OF Rate Sheet
Initials - ORG
1 *ELECTRONIC SIGNATURES REQUIRED FOR REVISED BUDGE T
MARY
PROPOSAL BUDGET
YEAR
2
FOR NSF USE ONLY
PROPOSAL NO.
ORGANIZATIO N
Cornell University - State
Proposed
PRINCIPAL INVESTIGATOR / PROJECT DIRECTO R
Granted
AWARD NO .
William M Trochim
d
A. SENIOR PERSONNEL: PI/PD, Co-PI's, Faculty and Other Senior Associates
( List each seParatel Y with title, A.7. show number in brackets )
1.
DURATION (months )
William M Trochim - none
P
CAL
Funds,
Requeste d B y
proposer
s
ACAD
SUM R
Funds
grante d by N S F
(if different )
0 .00
0 .00
0 .00 $
0 $
0.00
0.00
0 .00
0
0.00
0.00
0 .00
0 .00
0 .00
0 .00
0 .00
0 .00
0
0 .00
0
0
0
0
0
0
0
2.
3.
4.
5.
6. (
0) OTHERS (LIST INDIVIDUALLY ON BUDGET JUSTIFICATION PAGE)
7. ( 1) TOTAL SENIOR PERSONNEL (1 - 6)
B . OTHER PERSONNEL (SHOW NUMBERS IN BRACKETS )
1. (
0)
2. (
POST DOCTORAL ASSOCIATES
0) OTHER PROFESSIONALS (TECHNICIAN, PROGRAMMER, ETC .)
3. (
0)
4 .(
0) UNDERGRADUATE STUDENTS
0) SECRETARIAL - CLERICAL (IF CHARGED DIRECTLY)
5. (
6 .(
GRADUATE STUDENTS
0)OTHER
TOTAL SALARIES AND WAGES (A + B)
C . FRINGE BENEFITS (IF CHARGED AS DIRECT COSTS)
TOTAL SALARIES, WAGES AND FRINGE BENEFITS (A + B + C)
_
0_
D . EQUIPMENT (LIST ITEM AND DOLLAR AMOUNT FOR EACH ITEM EXCEEDING $5,000 . )
TOTAL EQUIPMENT
E . TRAVEL
1 . DOMESTIC (INCL . CANADA, MEXICO AND U.S . POSSESSIONS)
0
0
0
2 . FOREIGN
,.
15
F. PARTICIPANT SUPPORT COSTS
1 . STIPENDS
$
5,60 0
0
0
0
2. TRAVEL
3. SUBSISTENCE
4. OTHER
TOTAL NUMBER OF PARTICIPANTS
(
2)
TOTAL PARTICIPANT
COSTS
5,60 0
G. OTHER DIRECT COSTS
0
0
0
1 . MATERIALS AND SUPPLIES
2 . PUBLICATION COSTS/DOCUMENTATION/DISSEMINATION
3 . CONSULTANT SERVICES
4 . COMPUTER SERVICES
5 .5UBAWARD5
0
0
0
0
5_,600
6 . OTHER
TOTAL OTHER DIRECT COSTS
H . TOTAL DIRECT COSTS (A THROUGH G)
I . INDIRECT COSTS (F&A)(SPECIFY RATE AND BASE )
administrative allowance (Rate : 25 .0000, Base : 5600)
TOTAL INDIRECT COSTS (F&A )
J . TOTAL DIRECT AND INDIRECT COSTS (H + I)
K. RESIDUAL FUNDS (IF FOR FURTHER SUPPORT OF CURRENT PROJECTS SEE GPG II .C .6 .j .)
L. AMOUNT OF THIS REQUEST (J) OR (J MINUS K)
M . COST SHARING PROPOSED LEVEL
$
0
AGREED LEVEL IF DIFFERENT $
PI/PD NAME
William M Trochim
ORG . REP . NAME*
$
1,400
7,000
0
7,000 $
FOR NSF USE ONLY
INDIRECT COST RATE VERIFICATION
Date Checked
Date Of Rate Sheet
I nitials - ORG
2 *ELECTRONIC SIGNATURES REQUIRED FOR REVISED BUDGET
SUMMARY
Cumulative
PROPOSAL BUDGET
FOR NSF USE ONLY
ORGANIZATION
PROPOSAL NO .
Cornell University - State
Proposed
PRINCIPAL INVESTIGATOR / PROJECT DIRECTOR
Granted
AWARD NO.
William M Trochi m
A . SENIOR PERSONNEL: P1/PD, Co-PI's, Faculty and Other Senior Associate s
( List each seParatel Y with title, A .7 . show number in bracket s )
1.
DURATION (months )
William M Trochim - none
CAL
Pi
ACAD
ra*
s
SUM R
Funds
R equeste d B y
proposer
Fund s
granted by NSF
(if different )
0 .00
0 .00
0 .0 0 $
0 $
' 0 .00
0 .00
0 .00
0 .00
0 .00
0 .00
0
0
0 .00
0 .00
0 .00
0 .00
0 .00
0
2.
3.
4.
5.
6. (
7. (
) OTHERS (LIST INDIVIDUALLY ON BUDGET JUSTIFICATION PAGE)
1) TOTAL SENIOR PERSONNEL (1 - 6)
B . OTHER PERSONNEL (SHOW NUMBERS IN BRACKETS )
1 . ( 0) POST DOCTORAL ASSOCIATES
2. (
0) OTHER PROFESSIONALS (TECHNICIAN, PROGRAMMER, ETC .)
3. (
0)
4. (
0) UNDERGRADUATE STUDENTS
0) SECRETARIAL - CLERICAL (IF CHARGED DIRECTLY)
0)OTHER
5. (
6 .(
0
0 .00
GRADUATE STUDENTS
Q
0
0
Q
TOTAL SALARIES AND WAGES (A + B)
0
C . FRINGE BENEFITS (IF CHARGED AS DIRECT COSTS)
Q
TOTAL SALARIES, WAGES AND FRINGE BENEFITS (A + B + C)
Q
D. EQUIPMENT (LIST ITEM AND DOLLAR AMOUNT FOR EACH ITEM EXCEEDING $5,000 . )
TOTAL EQUIPMENT
E. TRAVEL
1 . DOMESTIC (INCL. CANADA, MEXICO AND U .S . POSSESSIONS)
Q
0
Q
2. FOREIGN
F. PARTICIPANT SUPPORT COSTS
1 . STIPENDS
2. TRAVEL
$
3 . SUBSISTENCE
4 . OTHER
TOTAL NUMBER OF PARTICIPANTS
26,40 0
0
0
0
(
4)
TOTAL PARTICIPANT COSTS
26 .400 I
G . OTHER DIRECT COSTS
1 . MATERIALS AND SUPPLIES
Q
2 . PUBLICATION COSTS/DOCUMENTATION/DISSEMINATION
3 . CONSULTANT SERVICES
Q
0
4 . COMPUTER SERVICES
0
5.5UBAWARD5
0
0
6 . OTHER
TOTAL OTHER DIRECT COSTS
Q
H . TOTAL DIRECT COSTS (A THROUGH G)
26
_ _40 0
I. INDIRECT COSTS (F&A)(SPECIFY RATE AND BASE )
6,60 0
33,00 0
TOTAL INDIRECT COSTS (F&A)
J . TOTAL DIRECT AND INDIRECT COSTS (H + I)
K. RESIDUAL FUNDS (IF FOR FURTHER SUPPORT OF CURRENT PROJECTS SEE GPG II .C .6 .j .)
L . AMOUNT OF THIS REQUEST (J) OR (J MINUS K)
M . COST SHARING PROPOSED LEVEL $
0
AGREED LEVEL IF DIFFERENT $
PIIPD NAM E
William M Trochim
ORG . REP. NAME*
0
$
33,000 $
FOR NSF USE ONL Y
INDIRECT COST RATE VERIFICATIO N
Date Checked
Date Of Rate Sheet
Initials - ORG
C *ELECTRONIC SIGNATURES REQUIRED FOR REVISED BUDGE T
Budget Justification Pag e
In year one, 5/25/06-5/23/07, two students will each be paid $10 per hour and will wor k
work 20 hours per week. In year two, 5/24/07-8/29/07, two students will each be paid $1 0
per hour and will work 20 hours per week .
SUPPLEMENTARY DOC S
Biographical Sketch-Anna Hay s
Anna Hays is a junior Human Development major in the College of Human Ecology at Cornel l
University . She has an impressive academic record including a 3 .9 cumulative GPA ,
memberships in Psi Chi and the Golden Key National Honor Society, and she was th e
recipient of the New York State Scholarship for Academic Excellence . In addition to her
recent research experience with Dr . Trochim, Ms . Hays also works as a research assistan t
in the Cornell Infant Studies Lab where her responsibilities include testing infants i n
habituation and preferential looking studies, data entry and coding, and interviewin g
parents . She has also worked as a research assistant at the Jacobs Neurological Institut e
in Buffalo, NY where she interviewed and tested patients with multiple sclerosis for th e
New York State Multiple Sclerosis Consortium . Ms . Hays also helped edit a questionnair e
used for a study of quality of life of children with epilepsy and their families . This
work was completed during her tenure as research assistant at the Women and Children? s
Hospital of Buffalo.
Biographical Sketch-Sabrina Rahman
Sabrina Rahman is a sophomore Human Biology, Health, and Society major in the College o f
Human Ecology at Cornell University . She has an impressive academic record including a
3 .52 cumulative GPA, a New York State Merit Scholarship, and is a member of the Nationa l
Society of Collegiate Scholars . Ms . Rahman has already made significant contributions t o
the NSF funded systems evaluation capacity building project by helping with the
identification and assessment of Cornell STEM education programs for consideration a s
prospective pilot sites. She has also conducted extensive literature reviews related t o
best practices in STEM education and evidence-based practice . In addition to her recen t
research experience with Dr . Trochim, Ms . Rahman also works as a research assistant in th e
Laboratory of Rational Decision Making where her responsibilities include the evaluatio n
of clinical guidelines and medical decision making for patients with unstable anginas .
She has also worked as a medical chemistry research intern at the North Shore-LI J
Institute for Medical Research . In this capacity, she investigated the efficacy o f
various drug designs in the inhibition of pro-inflammatory activity . In addition, she
received advanced training in several chemical techniques and assisted in drug synthesis ,
writing, and data analysis. Ms . Rahman plans on pursuing a career in the medica l
sciences .
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