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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