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Mesothelioma Applied Research Foundation Grant Application

By Kelly Collins,2014-06-26 20:42
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Mesothelioma Applied Research Foundation Grant Application ...

    Mesothelioma Applied Research Foundation Grant Program

    APPLICATION FORMAT

    ? APPLICATIONS MUST INCLUDE THE COVER FORM BELOW PLUS NO MORE THAN 10

    ADDITIONAL PAGES. THE FOLLOWING FORMAT IS SUGGESTED: ? ABSTRACT OF PROPOSED PROJECT AND SPECIFIC AIMS (1 PAGE) ? BACKGROUND, SIGNIFICANCE AND POTENTIAL FOR TRANSLATION (2 PAGES) ? PRELIMINARY STUDIES (2.5 PAGES)

    ? RESEARCH DESIGN AND METHODS (4 PAGES)

    ? TIMETABLE (.5 PAGE)

    ? REFERENCES (NOT COUNTED AGAINST 10 PAGE TOTAL)

    BUDGET GUIDELINES

    ? BUDGETS MAY NOT EXCEED $50,000 PER YEAR

    ? REQUESTS FOR EQUIPMENT ARE DISCOURAGED AND WILL BE

    CONSIDERED ONLY IN EXCEPTIONAL CIRCUMSTANCES ? SALARIES MAY BE BUDGETED

    ? INSTITUTIONAL INDIRECT COSTS OR OVERHEAD MAY NOT BE BUDGETED ? SUBCONTRACTS TO OTHER INSTITUTIONS ARE NOT PERMITTED. ALTHOUGH

    COLLABORATIVE PROJECTS WHERE ALL PARTICIPATING INSTITUTIONS JOINTLY

    APPLY ARE ENCOURAGED.

    ? PROJECT BUDGET AND JUSTIFICATION MUST BE IN PHS 398 FORMS INCLUDED

    ? BIOGRAPHICAL SKETCHES OF ALL PARTICIPATING INVESTIGATORS MUST BE

    INCLUDED (not included in the 10 page limit)

    ? OTHER SUPPORT OF ALL PARTICIPATING INVESTIGATORS MUST BE INCLUDED

?

     Mesothelioma Applied Research Foundation Grant

    Application

    PRINCIPAL INVESTIGATOR: ACADEMIC TITLE:

    UNIVERSITY, HOSPITAL OR INSTITUTE: DEPARTMENT:

    CITY/STATE/ZIP: STREET ADDRESS:

    E-MAIL ADDRESS: TELEPHONE:

    FAX: ASSISTANT NAME/EMAIL:

TITLE OF PROPOSAL:

    I LEARNED OF THE MESO FOUNDATION GRANT THROUGH (please be specific):

TWO SENTENCE PRECIS OF PROJECT:

    LAY DESCRIPTION OF PROJECT AND ITS APPLICABILITY (APPROXIMATELY 50 WORDS):

    AREA OF ELIGIBILITY (CLINICAL/TRANSLATIONAL/BENCHWORK):

ANIMALS? YES NO

    IF YES:

     DATE OF APPROVAL: LETTER ATTACHED? YES NO

    WE EACH CERTIFY THAT THE ABOVE NAMED UNIVERSITY, HOSPITAL OR INSTITUTE, AND ITS RESEARCHERS AND EMPLOYEES ADHERE TO THE ANIMAL WELFARE ACT, NATIONAL HEALTH COUNCIL GUIDE FOR THE CARE AND USE OF LABORATORY ANIMALS, AND ALL APPROPRIATE U.S. DEPARTMENT OF AGRICULTURE OR

    NATIONAL INSTITUTES OF HEALTH REGULATIONS AND STANDARDS REGARDING

    THE USE OF ANIMALS IN RESEARCH. YES NO

    HUMAN SUBJECTS? YES NO

     DATE OF APPROVAL:

     LETTER ATTACHED? YES NO

PROPOSED BUDGET:

SITE (S) OF PROPOSED PROJECT:

SIGNATURES/APPROVALS

    We each certify that to the best of our knowledge, the statements made in this application are true,

    complete and accurate, and that none of these statements constitute or incorporate any scientific

    misconduct, as defined by 42 CFR Part 50, Subpart A: "fabrication, falsification, plagiarism, or

    other practices that seriously deviate from those that are commonly accepted within the scientific

    community for proposing, conducting, or reporting research". Principal Investigator agrees to

    accept responsibility for the scientific conduct of the project. Financial Officer certifies that

    University, Hospital or Institute is a not for profit organization in good standing with all applicable

    governmental taxing agencies. Also, if the project is chosen for funding the Financial Officer will be

    able to agree to the following indemnity clause, “You and the Institute assume all responsibility for

    the proposed work of the Project, and the Institute will hold the meso Foundation and its officers,

    directors and employees harmless from any and all lawsuits, claims, judgment, damages, awards

    or losses, arising from the research, investigators or conduct of the project.”

______________________________ _____________

    PRINCIPAL INVESTIGATOR [signature] DATE

    _______________________________________ NAME OF UNIVERSITY, HOSPITAL OR INSTITUTE

By:

    ________________________________________________ [signature of University’s, Hospital’s or Institute’s Financial Officer]

______________________________________

    [print name and title of Financial Officer]

     Principal Investigator/Program Director (Last, First, Middle):

     FROM THROUGH DETAILED BUDGET FOR INITIAL BUDGET PERIOD

     DIRECT COSTS ONLY

     PERSONNEL (Applicant organization only) DOLLAR AMOUNT REQUESTED (omit cents) %

    TYPE EFFORT INST. SALARY FRINGE ROLE ON APPT. ON BASE REQUESTED BENEFITS TOTAL NAME PROJECT (months)PROJ. SALARY

    Principal Investigator

    SUBTOTALS CONSULTANT COSTS

EQUIPMENT (Itemize)

SUPPLIES (Itemize by category)

TRAVEL

    PATIENT CARE COSTS INPATIENT

    OUTPATIENT ALTERATIONS AND RENOVATIONS (Itemize by category)

OTHER EXPENSES (Itemize by category)

    CONSORTIUM/CONTRACTUAL COSTS DIRECT COSTS SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD (Item 7a, Face Page) $

    FACILITIES AND ADMINISTRATIVE COSTS CONSORTIUM/CONTRACTUAL COSTS TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD $ SBIR/STTR Only: FEE REQUESTED

     PHS 398 (Rev. 09/04)

    Principal Investigator/Program Director (Last, First, Middle):

     BUDGET FOR ENTIRE PROPOSED PROJECT PERIOD

    DIRECT COSTS ONLY

    INITIAL BUDGET ADDITIONAL YEARS OF SUPPORT REQUESTEDBUDGET CATEGORY PERIOD TOTALS 2nd 3rd 4th 5th (from Form Page 4)

    PERSONNEL: Salary and fringe benefits. Applicant organization only.

    CONSULTANT COSTS EQUIPMENT SUPPLIES TRAVEL

     INPATIENTPATIENT CARE COSTS OUTPATIENT ALTERATIONS AND RENOVATIONS OTHER EXPENSES CONSORTIUM/ DIRECT CONTRACTUAL COSTS

    SUBTOTAL DIRECT COSTS

    (Sum = Item 8a, Face Page) CONSORTIUM/ F&A CONTRACTUAL COSTS

    TOTAL DIRECT COSTS TOTAL DIRECT COSTS FOR ENTIRE PROPOSED PROJECT PERIOD $ SBIR/STTR Only

    Fee Requested SBIR/STTR Only: Total Fee Requested for Entire Proposed Project Period (Add Total Fee amount to “Total direct costs for entire proposed project period” above and Total F&A/indirect costs from Checklist Form Page, and enter these as “Costs Requested for Proposed Period of Support on Face Page, Item 8b.) $ JUSTIFICATION. Follow the budget justification instructions exactly. Use continuation pages as needed.

     PHS 398 (Rev. 09/04)

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