Department of Health and Human Services Public Health Service, Grant Application

Principal Investigator/Program Director (Last, first, middle):
CHECKLIST

Duesberg, Peter H.

err n en i n rw r -- r srr es r w

TYPE OF APPLICATION
NEW application. (This application is being submitted to the PHS for the first time.)
[] REVISION of application number:
(This application replaces a prior unfunded version of a new, competing continuation, or supplemental application.)
D COMPETING CONTINUATION of grant number:
(This application is to extenda funded grant beyond its current project period.)
SUPPLEMENT to grant number:
(This application is for additional funds to supplement a currently funded grant.)
[ CHANGE of principal investigator/program director.
Name of former principal investigator/program director:
[ FOREIGN application, city and county of birth and present citizenship of principal investigator/program director. (This information is required
by the U.S. Department of State.)
1. ASSURANCES/CERTIFICATIONS
The following assurances/certifications are made by checking the appropriate boxes and are verified by the signature of the OFFICIAL SIGNING FOR
APPLICANT ORGANIZATION on the FACE PAGE of the application. Descriptions of individual assurances/certifications begin on page 24 of Specific
Instructions.

a Human Subjects (Complete Item 4 on the Face Page)
[]Full IRB Review [J Expedited Review
b. Vertebrate Animals (Complete Item 5 on the Face Page)
c. Inventions and Patents (Competing Continuation Application Only-Complete Item 10on the Face Page)
d Debarment and Suspension. E No Yes (Attach explanation)
e. Dr -Free Workplace (Ap icable only to new or revised applications being submitted to the PHS for the first proposed project period Type 1)
X Yes No (Attach explanation) -
f. Lobbying
With Federal appropriated funds No

With other than Federal appropriated funds X No Yes
(Ies, see page 2a attach Standard Form LLL, "Disclosure of Lobbying Activities,R to the
application behind the second page of the Checklist.)
Delinquent Federal Debt No Yes (Attach explanation)
Misconduct in Science (Form PHS 6315) Filed []Not Filed
if filed, date of initial Assurance or latest Annual Report 01/14/92

g.
h.

i. Civil Rights
Form HHS 441
Filed
Not Filed

j. Handicapped Individuals
Form HHS 641
Filed
W Not Filed

k. Sex Discrimination
Form HHS 639-A
Filed
Not Filed

I. Age Discrimination
Form HHS 680
[]Filed
[]Not Filed

PHS398 (Rev. 991) Page 42 II

PHS398 (Rev. 9/91)

Page 42

II