Project title 

Not to exceed 60 characters including spaces and punctuation

Full Name of Primary Investigator (PI)

Degree(s)

Organization / Department

Email Address

Phone Number

Mailing Address

Total funding request

Direct costs in US Dollar

Proposed start date

Proposed end date

Human subjects

Research exempt from IRB / Ethical Approval

IRB / Ethical Committee approval, if required

If IRB / Ethical Committee approved, please upload document

Have you ever had funding rescinded for any reason?

If funding had been rescinded, please explain further

Principal investigator assurance

The information contained in this application is true and accurate. I am aware that any false, fictitious or fraudulent statements may incur criminal or administrative penalties.

Abstract

Clearly and concisely state the specific aims, research design and methods for achieving the aims, and clinical relevance of the proposed project. This abstract should accurately but briefly reflect the research plan section of the application and should stand as an independent document. If accepted for funding, this abstract will be published on the Foundation’s website

Maximum words: 350

Biographical Sketch

Please upload the biographical sketch for all investigators. A template can be find here.

Budget

The purpose of the budget and justification is to support all expenses required to complete the proposed research project’s specific aims. Only reasonable budgets will be considered. 
Insert only direct costs in US Dollar.

Total amount requested (USD)

Equipment - total costs in US Dollar

Equipment - itemization and justification

Consumable supplies - total costs in US Dollars

Consumable supplies - itemization and justification

Consultants - totals costs in US Dollar

Consultants - itemization and justification

Travel - total costs in US Dollar

Travel - itemization and justification

Other expenses (e.g. patient reimbursement) - total costs in US Dollar

Other expenses (e.g. patient reimbursement) - itemization and justification

Resources

List all resources pertinent to the implementation of the proposed project including location of resources. For clinical research, please list sites where research will be performed. Include letter from the clinic indicating agreement to participation in the appendix. For non-clinical research, please list large pieces of equipment that will be used (items not included in the budget) including location of item(s). Example – MRI scanner. Include letter from facility indicating agreement to participate in the appendix.

Facility - agreement 

If appropriate, please upload a letter from facility indicating agreement to participate.

One or more of the investigators of this project will or has received personal or professional benefits from a commercial party directly or indirectly related to the proposed project. List the investigator(s) and the benefit.

One or more of the investigators has a vested interest in a company or product related to the proposed project. List the investigator(s) and his/her interest.

Please provide explanation for any YES boxes checked on 33. or 34.

Specific Aims and Hypotheses

Limit: 400 words

Background and Significance

Limit: 1000 words

Preliminary Studies / Experiences

Limit: 700 words

Research Design and Methods

• Subjects - include power analysis to determine sample size
• Data collection
• Data analysis
• Study limitations

Limit: 2500 words

Timetable

Limit: 400 words

Literature Cited

Please use AMA style

Letters of Support/Agreement

Please upload all letters of support and/or letters of agreement in one file.

Appendix

Upload all documents in one file