common compliance pitfalls and strategies for success

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Common Compliance Pitfalls and Strategies for Success Division of Grants Compliance and Oversight Office of Policy for Extramural Research Administration, OER National Institutes of Health, DHHS NIH Regional Seminar – Baltimore, MD – June 2013 Diane Dean, Director Kathy Hancock, Assistant Grants Compliance Officer Sahar Rais, Assistant Grants Compliance Officer

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Common Compliance Pitfalls and Strategies for Success. Division of Grants Compliance and Oversight Office of Policy for Extramural Research Administration, OER National Institutes of Health, DHHS NIH Regional Seminar – Baltimore, MD – June 2013. Diane Dean , Director - PowerPoint PPT Presentation

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Page 1: Common Compliance Pitfalls and Strategies for Success

Common Compliance Pitfalls and Strategies for Success

Division of Grants Compliance and OversightOffice of Policy for Extramural Research Administration, OER

National Institutes of Health, DHHS

NIH Regional Seminar – Baltimore, MD – June 2013

Diane Dean, Director Kathy Hancock, Assistant Grants Compliance OfficerSahar Rais, Assistant Grants Compliance Officer

Page 2: Common Compliance Pitfalls and Strategies for Success

Division of Grants Compliance and Oversight

This Division was established on August 28, 2001 and is responsible for managing internal and external compliance activities, both proactive and for-cause.

Michelle BullsDirector, OPERA

Diane DeanDirector, Division of Grants Compliance and Oversight

John Burke, Kathy Hancock, Lisa Scott-Morring, Sahar Rais, and Joel Snyderman

Assistant Grants Compliance Officers

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Page 3: Common Compliance Pitfalls and Strategies for Success

Compliance is……• The effective management of public funds to

maximize research outcomes

• The avoidance of fraud, institutional mismanagement, and poor management of Federal funds

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Page 4: Common Compliance Pitfalls and Strategies for Success

What are grantees responsible for?

• Safeguarding all assets• Spending funds in accordance with the

authorized purpose• Developing and implementing systems to

ensure proper stewardship of fundso Financial management systemso Procurement systemso Time & effort reporting systemso Monitoring activitieso Adherence to terms & conditions of award

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Page 5: Common Compliance Pitfalls and Strategies for Success

Compliance Requirements

Institutional Policies• Organizational Structure• Purchasing • Accounting/Budgetary Controls • Time and Effort Reporting• Travel• Consulting • Property Management• Ethics/Conflict of Interest

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Page 6: Common Compliance Pitfalls and Strategies for Success

Compliance Requirements

Code of Federal Regulations (CFR)

• 42 CFR Part 52 – Grants for Research Projectshttp://www.access.gpo.gov/nara/cfr/waisidx_03/42cfr52_03.html

• 45 CFR Parts 74 and 92 – Public Welfare, Administrative Requirements(74) http://www.access.gpo.gov/nara/cfr/waisidx_04/45cfr74_04.html

(92) http://www.access.gpo.gov/nara/cfr/waisidx_04/45cfr92_04.html

• 45 CFR Part 46 – Public Welfare, Protection of Human Subjectshttp://www.access.gpo.gov/nara/cfr/waisidx_04/45cfr46_04.html

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Page 7: Common Compliance Pitfalls and Strategies for Success

Compliance Requirements

OMB Circulars - http://www.whitehouse.gov.ombcirculars

Administrative Requirements or Standards:

o A-102: Uniform Administrative Requirements for Grants and Cooperative Agreements awarded to State and Local Governments and Indian Tribes

o A-110 / 2 CFR Part 215: Uniform Administrative Requirements for Grants and Agreements awarded to Universities, Hospitals, and Other Non-Profit Organizations

These include pre-award and post-award requirements

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Page 8: Common Compliance Pitfalls and Strategies for Success

Compliance Requirements

Cost Principles: Applicable OMB Circulars and CFRs

o A-21 (2 CFR Part 220): Cost Principles for Educational Institutions

o A-87 (2 CFR Part 225): Cost Principles for State and Local Governments and Indian Tribes

o A-122 (2 CFR Part 230): Cost Principles for Non-Profit Organizations

o 45 CFR Part 74, Appendix E: Principles for Determining Costs Applicable to Hospitals

o 48 CFR Subpart 31.2 (Federal Acquisition Regulation) Applicable to For-profit organizations

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Page 9: Common Compliance Pitfalls and Strategies for Success

Compliance Requirements

Audit Requirements: Applicable OMB Circular and CFRo A-133: Audits of States, Local Governments, and

Non-Profit Organizationso 45 CFR Part 74.26 (d): Audits of For-Profit and Foreign Organizations

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Page 10: Common Compliance Pitfalls and Strategies for Success

Summary of Applicable RegulationsGrantee

Type Administrativ

e Requirements

Cost Principles Audit Requirements

State & Local Governments

A-102 (45 CFR Part 92)

A-87 (2 CFR Part 225)

A-133

_____________45 CFR Part 74.26(d)

Colleges & Universities

A-110 or2 CFR Part 215

A-21 (2 CFR Part 200)

Non-Profits A-122 (2 CFR Part 230)

Hospitals 45 CFR Part 74, Appendix E

For-Profits FAR 31.2(48 CFR Subpart 31.2)

Foreign As stated above for the grantee type

NIH GPS, uses 45 CFR Part 74.26(d)

Page 11: Common Compliance Pitfalls and Strategies for Success

Compliance Requirements

• NIH Grants Policy Statement (GPS)http://grants.nih.gov/grants/policy/nihgps_2012/

• Notice of Award (NoA)• NIH Guide to Grants and Contracts (for new

requirements)http://grants.nih.gov/grants/guide/index.html

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Page 12: Common Compliance Pitfalls and Strategies for Success

Compliance Pitfalls

• Unallowable costs• Misallocation of costs• Excessive cost transfers• Inaccurate effort reporting• Inadequate subrecipient monitoring• Administrative & Clerical costs• Noncompliance with Assurances and

special terms and conditions of award• Delinquent closeout reporting

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Page 13: Common Compliance Pitfalls and Strategies for Success

Case Studies with References

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Page 14: Common Compliance Pitfalls and Strategies for Success

Case Study 1…. A University employee transfers expenses

from one account to another and annotates the cost transfer “to correct an accounting error.”

Internal Audit takes exception. Why?

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Page 15: Common Compliance Pitfalls and Strategies for Success

References for Case Study 1

o Errors should be corrected within 90 days of when the error was discovered.

o Transfers must be supported by: Documentation that fully explains how the error occurred Certification of the correctness of the new charge (by a

responsible organization official)

o Transfers of costs from one project to another or from one competitive segment to the next solely to cover cost overruns are not allowable.

o All charges to grants must be reasonable, allowable, allocable, and consistently applied.

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Page 16: Common Compliance Pitfalls and Strategies for Success

Case Study 2…. You are asked by a PI to stop at an office

supply store on your way to work and pick up a few items (pens, envelopes and paperclips). The PI also asked you to get some donuts for a lab meeting that morning. When you arrive at work, the PI tells you that all of the items should be charged to the grant.

Your Departmental Administrator tells you that these purchases must come from Departmental funds. Why?

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Page 17: Common Compliance Pitfalls and Strategies for Success

References for Case Study 2

• If the office supplies are not specifically allocable to the grant, they are considered general office supplies and should not be charged as a direct cost to the grant account.

• Entertainment costs, such as food, are unallowable.

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Page 18: Common Compliance Pitfalls and Strategies for Success

More References for Case Study 2

• Meals are allowable on a research grant when: 1. they are provided by a conference grant (for

scientific meetings supported by the conference grant);

2. they are provided to subjects or patients under study provided that such charges are not duplicated in participant’s per diem or subsistence allowances, if any; and

3. such costs are specifically approved as part of the project activity in the NoA.

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Page 19: Common Compliance Pitfalls and Strategies for Success

More References for Case Study 2

• Meals may be an allowable cost, on a research grant, if they are provided in conjunction with a meeting when the primary purpose is to disseminate technical information.

• An institution must also have a written and

enforced policy in place that addresses the following:

o Ensures consistent charging of meal costso Defines what constitutes a meeting for the

dissemination of technical informationo Specifies when meals are allowable for such

meetingso Establishes limitations and other controls on this

cost

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Page 20: Common Compliance Pitfalls and Strategies for Success

More References for Case Study 2

REMEMBER:Recurring business meetings, such as staff meetings, are generally not considered meetings to disseminate technical information.

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Page 21: Common Compliance Pitfalls and Strategies for Success

Case Study 3….Dr. Admins from the University of Education submits a research grant application that seeks support for a half-time secretary, two laptops and a BlackBerry.

Are these types of costs appropriate for a traditional “R01” grant application?

            

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Page 22: Common Compliance Pitfalls and Strategies for Success

References for Case Study 3

• Administrative or Clerical Staff Salarieso Normally treated as F&A (indirect) costs.o Cost may be appropriate where a major project

or activity explicitly budgets for administrative or clerical

services and individuals involved can be specifically identified

with the project or activity. o A-21, Exhibit C, provides examples of “major

projects” where direct charging of these costs may be appropriate.

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Page 23: Common Compliance Pitfalls and Strategies for Success

References for Case Study 3 cont’d

• Materials and Supplies

oNIH considers the justification of ‘general use’ business items (e.g. laptop or blackberry) to determine if they are needed for a special research purpose. General office use is not sufficient justification.

oGeneral office purpose is allowable as an F&A cost.

oOnly materials and supplies actually used for the performance of a sponsored agreement may be charged as direct costs.

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Page 24: Common Compliance Pitfalls and Strategies for Success

References for Case Study 3 cont’d

• General Purpose Equipment o Unallowable as a direct cost except where

approved in advance by awarding agency

o Use is NOT limited to research, medical, scientific, or other technical activities Examples include office equipment and

furnishings, information technology equipment and systems, reproduction and printing equipment.

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Page 25: Common Compliance Pitfalls and Strategies for Success

References for Case Study 3 cont’d

• Special Purpose Equipment o Allowable as a direct costo Used only for research, medical, scientific,

or other technical activities Examples: microscopes, x-ray machines,

surgical instruments, spectrometers

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Page 26: Common Compliance Pitfalls and Strategies for Success

References for Case Study 3 cont’d

• Check with your institutional policy before including these types of costs in grant proposal budgets.

• Post award rebudgeting actions must also meet institutional and A-21 requirements.

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Case Study 4….A project leader on an NIH-funded program project grant (a P01 award) submitted a research (R01) grant application to NIH. The R01 application is selected for funding. Because the individual plans to spend 12 person months (100% effort) on the R01 project, the individual withdraws from the currently-funded P01 project.

1. Does the grantee institution need to obtain NIH prior approval for a change in status of

a Project Leader on a P01 award?

2. What if the P01 PD/PI wants to withdraw from the project? Is NIH prior approval required?27

Page 28: Common Compliance Pitfalls and Strategies for Success

References for Case Study 4

• Grantees are required to notify the NIH Grants Management Officer in writing if the PD/PI or Senior/Key personnel specifically named in the NoA will eithero withdraw from the project entirely, o be absent from the project during any continuous period of 3

months or more, o or reduce time devoted to the project by 25 percent or more

from the level that was approved at the time of award.• NIH must approve any alternate arrangement proposed

by the grantee, including any replacement of the PD/PI or Senior/Key personnel named in the NoA.

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Page 29: Common Compliance Pitfalls and Strategies for Success

References for Case Study 4 cont’d

The requirement to obtain NIH prior approval for a change in status pertains only to the PD/PI and those Senior/Key personnel NIH named in the NoA regardless of whether the applicant organization designates others as key personnel for its own purposes.

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Page 30: Common Compliance Pitfalls and Strategies for Success

Case Study 5….Dr. Miller purchases a much needed piece of specialized, scientific equipment for her research on hypertension. When preparing the purchase request, she realizes that the only account with enough money is her grant for research on sleep disorders. Because both grants are funded by NIH, she charges the equipment to the sleep disorder grant.

Is this appropriate?

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Page 31: Common Compliance Pitfalls and Strategies for Success

References for Case Study 5

The cost principles address four tests to determine allowability of costs:

• AllocabilityA cost is allocable to a specific grant if it is incurred solely to advance work under the grant and is deemed assignable, at least in part, to the grant.

• ReasonablenessA cost may be considered reasonable if the nature of the goods or services acquired reflect the action that a prudent person would have taken under the circumstances prevailing at the time the decision to incur the cost was made.

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Page 32: Common Compliance Pitfalls and Strategies for Success

References for Case Study 5 cont’d

• ConsistencyGrantees must be consistent in assigning costs. Although costs may be charged as either direct costs or F&A costs, depending on their identifiable benefit to a particular project or program, they must be treated consistently for all work of the organization under similar circumstances, regardless of the source of funding.

• Conformance Conformance with limitations and exclusions as contained in the terms and conditions of award—varies by type of activity, type of recipient, and other variables of individual awards.

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Page 33: Common Compliance Pitfalls and Strategies for Success

Case Study 6….You recently learned that a post-doc working on an NIH grant had not disclosed that he was debarred for defaulting on his college loan. Unfortunately, you determined that this situation has gone unreported for a period of three years and during that time his salary has been paid by NIH grant funds.

Now what?

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Page 34: Common Compliance Pitfalls and Strategies for Success

References for Case Study 6

• Immediately report the situation to your Office of Sponsored Research and to each NIH awarding component.

• Individuals debarred from eligibility cannot be paid from NIH grant funds and such charges are unallowable.

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Page 35: Common Compliance Pitfalls and Strategies for Success

References for Case Study 6 cont’d

• As of November 26, 2003, Debarment and Suspension is implemented as a term and condition of awardo 2 CFR Part 376 (HHS regulations that

implement the government-wide debarment and suspension system guidance)

o 2 CFR Part 180 (OMB guidelines on governmentwide debarment and suspension (nonprocurement)

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Page 36: Common Compliance Pitfalls and Strategies for Success

References for Case Study 6 cont’d

• Prior to drawdown of funds for each grant award, grantees must report to the NIH funding IC if the grantee or any of its principals:o Are presently excluded or disqualified;o Have been convicted within the preceding three years of any of

the offenses listed in 2 CFR 180.800(a) or had a civil judgment for one of those offenses within that time period;

o Are presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses listed in 2 CFR 180.800(a); or

o Have had one or more public transactions (Federal, State, or local) terminated within the preceding three years for cause or default.

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References for Case Study 6 cont’d

• Grantees must also immediately report to the NIH funding IC if at any time during the project period, including periods of no-cost extension, they discover:o That they failed to disclose information prior to

the drawdown of funds, oro Due to changed circumstances, the grantee or

any of its principles for the grant now meet the reporting criteria

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Page 38: Common Compliance Pitfalls and Strategies for Success

References for Case Study 6 cont’d

• “Lower tier” transactions (consortia, subcontracts, consultants, collaborators, and contractors that require the provision of goods or services that will equal or exceed $25,000) are also subject to the regulations.

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Page 39: Common Compliance Pitfalls and Strategies for Success

References for Case Study 6 cont’d

For lower tier transactions, grantees must:

• Verify that the person is not excluded or disqualified prior to entering into a lower tier covered transaction.

• Require participants to (a) comply with the HHS Debarment and Suspension regulations as a condition of participation in the transaction and (b) pass the requirement to comply with regulations to each person involved in the covered transaction at the next lower tier.

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Page 40: Common Compliance Pitfalls and Strategies for Success

References for Case Study 6 cont’d

• Lower tier participants and contractors under grants (where the contract requires the provision of goods or services that will equal or exceed $25,000) must report to the grantee if it or any participants are presently excluded or disqualified.

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Page 41: Common Compliance Pitfalls and Strategies for Success

Additional Information Related to Case Study 6

Q: What is the System for Award Management (SAM) and Excluded Parties Lists System (EPLS)?

A: The System for Award Management (SAM) is the Official U.S. Government system that consolidated the capabilities of CCR/FedReg, ORCA, and EPLS. EPLS is the electronic version of the Lists of Parties Excluded from Federal Procurement and Nonprocurement Programs (Lists), which identifies those parties excluded throughout the U.S. Government (unless otherwise noted) from receiving Federal contracts or certain subcontracts and from certain types of Federal financial and nonfinancial assistance and benefits. https://www.sam.gov/portal/public/SAM/

General Information:https://www.sam.gov/portal/public/SAM/?portal:componentId=3c9caa24-5c93-4ce9-877a-b244446a54e9&portal:type=action&interactionstate=JBPNS_rO0ABXc0ABBfanNmQnJpZGdlVmlld0lkAAAAAQATL2pzZi9uYXZpZ2F0aW9uLmpzcAAHX19FT0ZfXw**

HHS Debarment Regulation: published in 2 CFR Part 376 implement the government-wide debarment and suspension system guidance (2 CFR Part 180)

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Page 42: Common Compliance Pitfalls and Strategies for Success

Case Study 7….You were recently informed that a foreign sub-recipient had not completed its annual audit. You contact the foreign university and are assured that they are in compliance with their country’s regulations and they do not have to comply with U.S. requirements.

Is this correct?

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Page 43: Common Compliance Pitfalls and Strategies for Success

References for Case Study 7

• Foreign recipients of NIH grant funds are subject to the same audit requirements as for-profit organizations. These requirements are specified in 45 CFR 74.26(d) and in the NIH Grants Policy Statement "Grants to For-Profit Organizations.“

• In summary, these requirements apply if, during its fiscal year, the organization expends $500,000 or more in Federal:o Grants;o Cooperative Agreements; and/oro Procurement Contracts.

• Audit options include:o A financial-related audit (as defined in, and in accordance with, the Generally Accepted

Government Auditing Standards (commonly known as the "Yellow Book"), of all the HHS awards; or

o An audit that meets the requirements of OMB Circular A-133.

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Page 45: Common Compliance Pitfalls and Strategies for Success

Related Excerpts from NIH Grants Policy Statement

• Case Study 1:Issue 1: Cost TransfersExcerpt from NIH GPS: Chapter 7.5 Cost Transfers,

Overruns, and Accelerated and Delayed Expenditures:

http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch7.htm#cost_transfersoverruns_accelerated_delayed_expedituresIssue 2: Cost Principles – 4 testsExcerpt from NIH GPS: Chapter 7.2 The Cost Principles:

http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch7.htm#cost_principles

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Page 46: Common Compliance Pitfalls and Strategies for Success

Related Excerpts from NIH Grants Policy Statement

• Case Study 2:Issue 1: Carryover of Unobligated BalancesExcerpt from NIH GPS: Chapter 8.1.2.4 Carryover of

Unobligated Balances:http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch8.htm#_Toc271264933Issue 2: Extension of Final Budget PeriodExcerpt from NIH GPS: Chapter 8.1.1.3 Extension of Final

Budget Period of a Previously Approved Project Period without Additional NIH Funds:

http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch8.htm#_Toc271264927

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Related Excerpts from NIH Grants Policy Statement

• Case Study 3:Issue: Allowability of charging administrative staff salaries, general supplies and equipment costs as direct costs to NIH grants. Excerpts from the cost principles OMB Circular A-21 or 2 CFR Part 220

(Appendix A) (see: J.18 and Exhibit C):

o http://www.whitehouse.gov/omb/circulars/a021/a21_2004.html#j o http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=4dabe524408cc4bc5f7

060e27ccb1486&rgn=div9&view=text& node=2:1.1.2.10.4.0.15.10.6&idno=2

• Case Study 4:Issue: Change in Senior/Key Personnel Named in the Notice of Award (NoA)Excerpt from NIH GPS: Chapter 8.1.2.6 Administrative Requirements,

Changes in Project and Budget, Prior Approval Requirements – Change in Status, Including Absence, of PD/PI and Other Senior/Key Personnel:

o http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch8.htm#_Toc27126493547

Page 48: Common Compliance Pitfalls and Strategies for Success

Related Excerpts from NIH Grants Policy Statement

• Case Study 5:

Issue: Cost Principles – 4 testsExcerpt from NIH GPS: Chapter 7.2 The Cost Principles:

http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch7.htm#cost_principles

• Case Study 6:

Issue: Using Federal Grant Funds to Pay a Debarred Individual

Excerpt from NIH GPS: Chapter 4.1.6 Debarment and Suspension

http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch4.htm#debarment_suspension

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Related Excerpts from NIH Grants Policy Statement

• Case Study 7:

Issue 1: Foreign Sub-Recipient A-133 Audit Requirements

Excerpt from NIH GPS: Chapter 16.7.4 Grants to Foreign Institutions, International Organizations, and Domestic Grants with Foreign Components:

http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch16.htm#_Toc271265286

Excerpt from NIH GPS: Chapter 18.4.5 Grants to For-Profit Organizations, Administrative Requirements, Audit:

http://grants.nih.gov/grants/policy/nihgps_2012/nihgps_ch18.htm#_Toc271265313

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