Seattle Children's Urologic Management to Preserve Initial Renal Function Protocol for Young Children with Spina Bifida (UMPIRE Protocol) (Component C)

0MB Number: 4040-0001
Exnlratlon Date: 10/3112019
APPLICATION FOR FEOERAL ASSISTANCE
SF 424 (R&R)
1. TYPE OF SUBMISSION
D Pre-application cg] Application D Changed/Corrected Application
2. DATE SUBMITTED
I I
3. DATE RECEIVED BY STATE
I I
4. a. Federal Identifier
b. Agency Routing Identifier
c. Previous Grants.gov
Applicant Identifier
I
State Application Identifier
Tracking ID
5. APPLICANT INFORMATION Organizational DUNS: lo486821s10000 I
·
Legal Name: jseattle Children I s Hospital I
Department: [ I Division: I I
Street1: l·soo Sand Po~nt Way NE I
Street2: f I
City: lseattle ICounty I Parish: I I
State: I WA: Washington I Province: I I
Country: I USA: UNITED STATES I ZIP / Postal Code: 198105-3901 I
Person to be contacted on matters !nvolvlng this application
Prefix: lor. I First Name: !James I Middle Name: IB. I
Last Name: [Hendricks . 1 Suffix: I
Pos!tionffitle: !President, Research Institute I
Street1: j1900 Ninth Avenue I
Street2: IM/S 818-S I
City: lseattle ICounty I Parish: [King I
State: I WA: Washington I Province: I I
Country: I USA: UNITED STATES IZIP/ Postal Code: 198101-1309 I
Phone Number: 1206-884-7478 I Fax Number: 1206-884-1597 I
Email: lresactmin@seattlechildrens.org I
6. EMPLOYER IDENTIFICATION (EIN) or/TIN): 191-0564748 I
7. TYPE OF APPLICANT: f M: Nonprofit with 501C3 IRS Status (Other than Institution of Higher Education)
I
Other (Specify): I l
Small Business Organlzation Type D Women Owned D Socially and Economically Disadvantaged
If Revision, mark appropriate box(es).
DA. Increase Award DB. Decrease Award c. Increase Duration DD. Decrease Duratton
DE. Other (specify):I I
8. TYPE OF APPLICATION:
cg] New D Resubmission
D Renewal D Continuation Revision
Is this appllcatlon being submitted to other agencies? Yes O No rgj What other Agencies? I
9. NAME OF FEDERAL AGENCY:
!Centers for Disease Control and Prevention -
ERA
10. CATALOG OF FEDERAL DOMESTIC ASSISTANCE NUMBER:!93. 315
TITLE: IRare Disorde:i:·s: Research, Surveillance, Health Promotion,
and Education
11. DESCRIPTIVE TITLE OF APPLICANT'S PROJECT:
!Seattle Children's Urologic Management to Preserve Initial Renal Function Protocol for Young Children with Spina
Eifida (UMPIRE Protocol) (Component C}
12. PROPOSED PROJECT:
Start Date Ending Date
I 09/01/2019 11 0013112024
13. CONGRESSIONAL DISTRICT OF APPLICANT
lwA-007 II
9001050 11
SF 424 (R&R) APPLICATION FOR FEDERAL ASSISTANCE Page 2
14. PROJECT DIRJ;CTOR/PRINCIPAL INVESTIGATOR CONTACT INFORMATION
Prefix: -~r. I First Name: lwilliam I Middle Na~m_e_:_Ll:,o=t=i=s===;--------'I
Last Name: 11!'.w;al'.:k=·=r================,------'lSuffix: cclJ"-r'-.- - - ~ '
Position/Title: IL---;:===============:_I_____-----,
Organization Name: jseattle Children I a Hospital I
Pepartmen.:t:11::============c.._l_:D:_:iv:_:is:_:lo_n_:"=====;--------'I
Street1: [4a()o sand J?oint Way NE I
Street2:, I I
s============;-:--:--~~==--------
CIty: lseattle j County/ Parish: I I
State: I WA, Washington j Prmilnce: l'------;===========lc..__~
Country: ~,=====,====U=SA=,=UN::'I::'T::'E::'D::'S:::T::'A::'TE=S========;Z-'I,P/ Postal Code: "'9-'8"-0l'-5'---..C.3_90__1 _ _ _ _ _ _ _~1
Phone Number: j206-981-2000 j Fax Number: 1206-987-7818 I
Email: lwilliam. walker@seattlech>ildrens ,org
16. IS APPLICATION SUBJECT TO REVIEW BY STATE EXECUTIVE ORDER
12372 PROCESS?
a. YES O TNIS PREAPPLICATION/APPLICATION WAS MADE
AVAILABLE TO THE STATE EXECUTIVE ORDER 12372
PROCESS FOR REVIEW ON:
DATE: I I
b. NO [8;l PR~.GRAM IS NOT COVERED BY E,O. 12372; OR
 PROGRAM HAS NOT BEEN SELECTED BY STATE FOR
REVIEW
15. ESTIMATED PROJECT FUNDING
1-------------;::========;-I
a. Total Federal Funds Requested I 102, 495_ ool
b. Total Non~Federal Funds I o.ool
c. Total Federal & Non·Federal Funds I 102,495.001
d, Estimated Program Income I o. ool
17. By signing this application, I certify {1) to the statements contained in the list of certifications* and (2) that the statements herei~ are
true, complete and accurate to the best of my knowledge. I also provide the required assurances* and agree to comply With any resulting
terms if I accept an 'award. I am aware that any false, fictitious. or fraudulent statements or claims may subject me to criminal, civil, or
administrative penalties. (U.S. Code, Title 181 Section 1001)
~ I agree
*The llsf of certifications and assurances, or an Internet site where you may obtain this /Isl, Is contained In tho announcement or agency specific instructions.
18. SFLLL (Dfsclosure of Lobbying Activities) or other Explanatory Documentation
lrl.~. ~/-id~)~,,~\t=~c~b~.in-e~Qt-,·~11 )ji,1~te/\Uaq1Jrni,of·.11 ·· Vi~WAitaclirrteni ·. I
19. Authorized Representative
Prefix: lor. I First Name: !James I Middle Name: la. I
~-====::::;------'
Last Name: !Hendricks 7 Suffix: I I
'--;:::==============~----' '------1
Pos1tlon[fltle: !President, Research Institute I
Organization: [seattle children 1 s Hospital
Department l~===========:'_ID_1v_1s_1o_n_,:======:;--_____Jl
Street1: 11900 Ninth Avenue !
Street2: I