Quarterly Report

Attachment M

OMB APPROVAL NUMBER: 0693-0009

APPROVAL EXPIRES MM/DD/YYYY

BRS QUARTERLY REPORT

Section 1: Administrative Information

Company Name and Location

The information shown below refers to your company. Please verify the accuracy of this information.

COMP_NAME Company Name: [COMP_NAME]

UNIT_NAME Division Name: [ ]

ESTAB_ADD1 Address Line 1: [ ]

ESTAB_ADD2 Address Line 2: [ ]

ESTAB_ADD3 Address Line 3: [ ]

ESTAB_CITY City: [ ]

ESTAB_STATE State: [ ]

ESTAB_ZIP Zip: [ ]

ESTAB_WEB Website Address: [ ]

[Programmer note: Prefill company name and address info where available]

[Programmer Note: TCON_FNAME and TCON_LNAME are required fields]

[If TYPE_OF_PARTICIPATION = SA or JVL]

Principal Investigator

The Principal Investigator named in the terms and conditions of your ATP Cooperative Agreement is responsible for the overall direction and supervision of the ATP-funded project.

[If TYPE_OF_PARTICIPATION = JVP]

Technical Contact

The Technical Contact person for your company should be a mid- to senior-level person with responsibility for direction and supervision of technical work on this ATP-funded project.

TCON_CONFIRM

Our records indicate that [TCON_FNAME TCON_LNAME] is the [Principal Investigator] [your company’s Technical Contact]. Is this information correct?

Yes 1

No 2

If TCON_COMFIRM=Yes:

Please verify the following information for [TCON_FNAME TCON_LNAME].

TCON_FNAME First Name

TCON_LNAME Last Name

TCON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

TCON_TITLE Position Title

TCON_GNDR Gender Male____ Female ______

TCON_ORG1 Organization Name Line 1

TCON_ORG2 Organization Name Line 2

TCON_ADD1 Street Address Line 1 (no PO Box addresses, please)

TCON_ADD2 Street Address Line 2:

TCON_ADD3 Street Address Line 3

TCON_CITY City

TCON_STATE State

TCON_ZIP Zip

TCON_PHONE Telephone

TCON_EXT Ext.

TCON_FAX Fax

TCON_EMAIL E-mail

[Programmer note: Pre-fill TCON info if available.]

[If TCON_CONFIRM = NO AND TYPE_OF_PARTICIPATION = SA or JVL]

Principal Investigator

Please identify the Principal Investigator from the following list of personnel, or add a new name.

[If TCON_CONFIRM = NO AND TYPE OF PARTICIPATION = JVP]

Technical Contact

Please identify your company’s Technical Contact from the following list of personnel, or add a new name.

[DROP DOWN LIST OF ALL CONTACT NAMES]

[IF OLD NAME IS SELECTED FROM LIST]

Please verify the following information for [TCON_FNAME TCON_LNAME].

TCON_FNAME First Name

TCON_LNAME Last Name

TCON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

TCON_TITLE Position Title

TCON_GNDR Gender Male____ Female ______

TCON_ORG1 Organization Name Line 1

TCON_ORG2 Organization Name Line 2

TCON_ADD1 Street Address Line 1 (no PO Box addresses, please)

TCON_ADD2 Street Address Line 2:

TCON_ADD3 Street Address Line 3

TCON_CITY City

TCON_STATE State

TCON_ZIP Zip

TCON_PHONE Telephone

TCON_EXT Ext.

TCON_FAX Fax

TCON_EMAIL E-mail

[Programmer note: Pre-fill new TCON info if available.]

[IF ADD NEW TCON NAME IS SELECTED AND TYPE_OF_PARTICIPATION = SA or JVL]

Please complete the following contact information for your new Principal Investigator.

[IF ADD NEW TCON NAME IS SELECTED AND TYPE OF PARTICIPATION = JVP]

Please complete the following contact information for your new Technical Contact.

TCON_FNAME First Name

TCON_LNAME Last Name

TCON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

TCON_TITLE Position Title

TCON_GNDR Gender Male____ Female ______

TCON_ORG1 Organization Name Line 1

TCON_ORG2 Organization Name Line 2

TCON_ADD1 Street Address Line 1 (no PO Box addresses, please)

TCON_ADD2 Street Address Line 2:

TCON_ADD3 Street Address Line 3

TCON_CITY City

TCON_STATE State

TCON_ZIP Zip

TCON_PHONE Telephone

TCON_EXT Ext.

TCON_FAX Fax

TCON_EMAIL E-mail

[Programmer Note: BCON_FNAME and BCON_LNAME are required fields]

Business Contact

The Business Contact person for your company should be a mid- to senior-level person with responsibility for business development and commercialization aspects of this ATP-funded project.

BCON_CONFIRM

Our records indicate that [BCON_FNAME BCON_LNAME] is your company’s Business Contact. Is this information correct?

Yes 1

No 2

If BCON_CONFIRM=Yes:

Please verify the following information for [BCON_FNAME BCON_LNAME].

BCON_FNAME First Name

BCON_LNAME Last Name

BCON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

BCON_TITLE Position Title

BCON_GNDR Gender Male____ Female ______

BCON_ORG1 Organization Name Line 1

BCON_ORG2 Organization Name Line 2

BCON_ADD1 Street Address Line 1 (no PO Box addresses, please)

BCON_ADD2 Street Address Line 2:

BCON_ADD3 Street Address Line 3

BCON_CITY City

BCON_STATE State

BCON_ZIP Zip

BCON_PHONE Telephone

BCON_EXT Ext.

BCON_FAX Fax

BCON_EMAIL E-mail

[Programmer note: Pre-fill BCON info if available.]

If BCON_CONFIRM= No:

Please identify your company’s Business Contact from the following list of personnel, or add a new person.

[DROP DOWN LIST OF ALL CONTACT NAMES]

[IF OLD NAME IS SELECTED FROM LIST]

Please verify the following information for [BCON_FNAME BCON_LNAME].

BCON_FNAME First Name

BCON_LNAME Last Name

BCON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

BCON_TITLE Position Title

BCON_GNDR Gender Male____ Female ______

BCON_ORG1 Organization Name Line 1

BCON_ORG2 Organization Name Line 2

BCON_ADD1 Street Address Line 1 (no PO Box addresses, please)

BCON_ADD2 Street Address Line 2:

BCON_ADD3 Street Address Line 3

BCON_CITY City

BCON_STATE State

BCON_ZIP Zip

BCON_PHONE Telephone

BCON_EXT Ext.

BCON_FAX Fax

BCON_EMAIL E-mail

[Programmer note: Pre-fill new BCON info if available.]

[IF ADD NEW BCON NAME IS SELECTED]

Please complete the following contact information for your new Business Contact.

BCON_FNAME First Name

BCON_LNAME Last Name

BCON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

BCON_TITLE Position Title

BCON_GNDR Gender Male____ Female ______

BCON_ORG1 Organization Name Line 1

BCON_ORG2 Organization Name Line 2

BCON_ADD1 Street Address Line 1 (no PO Box addresses, please)

BCON_ADD2 Street Address Line 2:

BCON_ADD3 Street Address Line 3

BCON_CITY City

BCON_STATE State

BCON_ZIP Zip

BCON_PHONE Telephone

BCON_EXT Ext.

BCON_FAX Fax

BCON_EMAIL E-mail

Administrative Contact

The Administrative Contact person is responsible for administrative issues relating to the ATP Cooperative Agreement, including managing contract, budget, and related matters.

ACON_CONFIRM

Our records indicate that [ACON_FNAME ACON_LNAME] is your company’s Administrative Contact. Is this information correct?

Yes 1

No 2

If ACON_CONFIRM = Yes:

Please verify the following information for [ACON_FNAME ACON_LNAME].

ACON_FNAME First Name:

ACON_LNAME Last Name:

ACON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

ACON_TITLE Position Title:

ACON_GNDR Gender: Male____ Female ______

ACON_ORG1 Organization Name Line 1:

ACON_ORG2 Organization Name Line 2:

ACON_ADD1 Street Address Line 1 (no PO Box addresses, please):

ACON_ADD2 Street Address Line 2:

ACON_ADD3 Street Address Line 3:

ACON_CITY City:

ACON_STATE State:

ACON_ZIP Zip:

ACON_PHONE Telephone:

ACON_EXT Extension:

ACON_FAX Fax:

ACON_EMAIL E-mail:

[Programmer note: Pre-fill ACON info if available.]

If ACON_CONFIRM = No:

Please identify your company’s Administrative Contact from the following list of personnel, or add a new person.

[DROP DOWN LIST OF ALL CONTACT NAMES]

[IF OLD NAME IS SELECTED FROM LIST]

Please verify the following information for [ACON_FNAME ACON_LNAME].

ACON_FNAME First Name:

ACON_LNAME Last Name:

ACON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

ACON_TITLE Position Title:

ACON_GNDR Gender: Male____ Female ______

ACON_ORG1 Organization Name Line 1:

ACON_ORG2 Organization Name Line 2:

ACON_ADD1 Street Address Line 1 (no PO Box addresses, please):

ACON_ADD2 Street Address Line 2:

ACON_ADD3 Street Address Line 3:

ACON_CITY City:

ACON_STATE State:

ACON_ZIP Zip:

ACON_PHONE Telephone:

ACON_EXT Extension:

ACON_FAX Fax:

ACON_EMAIL E-mail:

[Programmer note: Pre-fill new ACON info if available.]

[IF ADD NEW ACON NAME IS SELECTED]

Please complete the following contact information for your new Administrative Contact.

ACON_FNAME First Name:

ACON_LNAME Last Name:

ACON_SALUT [Drop down box with following options: Dr., Mr., Miss, Mrs., Ms.]

ACON_TITLE Position Title:

ACON_GNDR Gender: Male____ Female ______

ACON_ORG1 Organization Name Line 1:

ACON_ORG2 Organization Name Line 2:

ACON_ADD1 Street Address Line 1 (no PO Box addresses, please):

ACON_ADD2 Street Address Line 2:

ACON_ADD3 Street Address Line 3:

ACON_CITY City:

ACON_STATE State:

ACON_ZIP Zip:

ACON_PHONE Telephone:

ACON_EXT Extension:

ACON_FAX Fax:

ACON_EMAIL E-mail:

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