FOR OFFICE USE ONLY - WHO



|FOR OFFICE USE ONLY |Date Received: |ID: |

|A. Summary of Administrative Information |

|1. Project title: |

|2. Principal investigator (PI) and contact details |

|For name, use the format: Salutation, Last name, First name. For example, Dr Smith, John. |

|Name: | |

|Job title: | |

|Age at last birthday (years): | |

|Sex (M/F): | |

|Phone: | |

|Fax: | |

|E-mail-1 (mandatory): | |

|E-mail-2 (optional): | |

|3. PI's affiliate institution (address must include city and country) |

|Institution name: | |

|Postal address: | |

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|Website (if any): | |

|4. PI's postal address (if different from above): |

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|5. Co-principal investigators, if any |

|For name, use the format: Salutation, Last name, First name. For example, Dr Smith, John. |

|Name: | |

|Job title: | |

|Age at last birthday (years): | |

|Sex (M/F): | |

|Phone: | |

|Fax: | |

|E-mail-1 (mandatory): | |

|E-mail-2 (optional): | |

|6. CO-PI's postal address (include city and country): |

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|7. Project manager and contact details (if different from PI): |

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|8. Organization responsible for this project (if different from PI's affiliated institution): |

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|9. Collaborating institutions, if any: |

|List institution name, city and country. If no, indicate "None". |

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|10. Project location (include city and country): |

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|11. Project budget ($US): |

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|12. Project duration (in months): |

|12.1 Estimated start date: |12.2 Estimated finish date: |

|13. Other funding agency (for administrative purpose only, not for application evaluation) |

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|Is this project linked to or part of other projects? (if so, please comment) Yes No |

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|Is this project part of a study funded by another funding agency? Yes No |

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|(If yes, please specify the agency and amount of funds) ______________________________ |

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|Is this project conditional to additional funding from other sources? Yes No |

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|Comments (if any) |

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|14. Financing and insurance: |

|Illustrate that the institution has the ability and capacity to administer the grant. |

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|15. Other research activities of the principal investigator: |

|Please list any relevant research projects in which the PI is involved, the source of funding of those projects, the duration of those projects|

|and the percentage of time spent on each. |

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|16. Details of relevant ethics review committee |

|Please note: evidence of local Ethics approval is not required during the application process. It will be required if your proposal is selected|

|for consideration. |

|16.1 Approval from relevant local ethics committee: |

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|Approval already received (evidence can be made available upon request) |

|Approval will be sought if selected for consideration |

|Other (please specify): |

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|16.2 Which local ethics committee is relevant to this study? |

|Name of the committee: | |

|Name of contact person (Salutation, Last name, First name): | |

|His/her role in the committee: | |

|His/her email: | |

|His/her fax number: | |

|B: Project Management and Organisation |

|17. Co-investigators (add more lines if needed) |

|For name, use the format: Salutation, Last name, First name. For example, Dr Smith, John. |

|Name |Sex (M/F) |Job title, affiliated institution, country, role in the |Email address |

| | |project (e.g. Director, xx hospital, xxx) | |

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|18 . Project team and project management |

|List project team members both academic and administrative staff that are additional to co-investigators. |

|Describe their role and responsibilities. |

|For name, use the format: Salutation, Last name, First name. For example, Dr Smith, John. |

|Name |Sex (M/F) |Job title, affiliated institution, country, role in the |Email address |

| | |project (e.g. Director, xx hospital, xxx) | |

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|19 Attachments |

|Attach CVs of PI and co-investigators to the online application form. |

|Maximum 4 pages each. Please combine them into one file. |

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