ࡱ> prmnoq` .bjbjqPqP \::v%71,,,,8LDlXڟڟڟ___6U1 $~hp1f_ff1,,ڟڟFnnnf,lڟڟnfnn,aڟ` +F*FA \0FVVaVa_rnq\ͥ___11^___ffffv|}D|},,,,,,  Northern Ireland Chest Heart & Stroke Research Grant Application Please return one copy by e-mail and one copy by post with all relevant signatures  1. Applicants (please continue on a separate sheet as necessary) Applicant(s)  Applicant 1 Applicant 2 Applicant 3 Surname Forename(s) Title Age Post held Hours p/w on project Institution/Authority (in which the lead applicant is employed and which will administer any approved award) Tel: ........................................... Fax: ........................................ Addresses at which work will be carried out: Title of investigation Abstract of research (not exceeding 250 words) 5. Proposed starting date Proposed duration (in months)  6. Total amount of grant requested NICHSA does not usually support the cost of equipment 7. Summary of support requested in Year 1 Year 2 Year 3 Total  Staff Consumables Travel & subsistence Exceptional items Equipment TOTAL  8. Has the project received Ethical approval? Yes / No Applied for . 9. Declaration by Applicants I have read the standard conditions of grant set out in the notes Research Conditions for Grant Holders and agree to abide by them and any amendments which may subsequently be issued. I shall be actively engaged in, and in day-to-day control of, the project. To be signed by  Signature Name in CAPITAL letters Date Applicant 1  Applicant 2  Applicant 3 Continue as necessary 10. This application should be submitted by/through the Head of Department and The Chief Financial Officer of the Health Trust, University or other organisation who will be responsible for administering any grant that may be awarded. Each should sign the following declaration: I confirm that I have read this application and that, if granted, the work will be accommodated and administered in the Department/Institution in accordance with the conditions in the notes Research Conditions for Grant Holders. The staff gradings and salaries quoted are correct and in accordance with the normal practice of this Department/Institution and account has been taken of anticipated cost of living increase and employers contributions. (i) Signature of Head of Department/Institution (ii) Signature of Chief Financial Officer ______________________________ _______________________________ Title ______________________________ Title _______________________________ Name and initials: Name and initials: _______________________________ _________________________________ Department/Institution: Department/Institution: _______________________________ _________________________________ Address: Address: _______________________________ __________________________________ _______________________________ __________________________________ _______________________________ __________________________________ Date: ___________________________ Date: _____________________________ 11. Proposed investigation Please use the following headings and incorporate this section into the body of the application form Title Purpose Clear statement of hypothesis or main study question Background Plan of investigation Justification of sample size Detailed justification for support requested Continue on no more than 5 separate A4 sheets - applications which exceed this length will be returned as unacceptable. History of the proposed research. Please provide a summary of the teams relevant research experience 13. Is your research being supported by any other funding? If YES please indicate: (i) the topic, (ii) the supporting organisation, (iii) the value, (iii) the tenure 14. Is this a related application currently being submitted elsewhere? If YES please indicate: (i) to which organisation, (ii) by what date is a decision expected 15. Has this application been submitted elsewhere over the past year? If YES please indicate: (i) to which organisation, (ii) what was the result, (iii) if it was subject to Peer Review, (iv) have you copies of the anonymised Peer Reviews? 16. Is the proposed research likely to lead to better methods of treatment or prevention of chest, heart or stroke illnesses? If YES please give brief details (continue overleaf as necessary): Full official postal address of all applicants Applicant 1: Name Department Institution Address Postcode Telephone No Alternative telephone no Fax No E-Mail Applicant 2: Name Department Institution Address Postcode Telephone No Alternative telephone no Fax No E-Mail Applicant 3: Name Department Institution Address Postcode Telephone No Alternative telephone no Fax No E-Mail 18. Full postal address of all collaborators A copy of a statement of willingness to co-operate should be enclosed with the application. Collaborator 1: Name Department Institution Address Postcode Telephone No (include area code) Fax No E-mail Collaborator 2: Name Department Institution Address Postcode Telephone No Fax No E-mail Collaborator 3: Name Department Institution Address Postcode Telephone No Fax No E-mail 19. Please describe here the statistical rationale for the study design. Where possible, indicate the main outcome measures and provide a sample size calculation based on this measure. Where appropriate, please show that assembling the required number of participants is feasible within the timeframe of the project. Please describe in terms understood by the public, who do not have a grasp of medical or scientific terminology, the nature and purpose of your proposed research. The scientific committee places much emphasis on the information in this section. 21. Details of Support requested (summarised in section 6 of the application form) Details of posts (see notes) Name GradeStart point on scale Incremental date Starting salary Other allowancesCombined superann & National insuranceCosts in Year 1 TOTAL(A1) Research staff 1 2 3 4(B1) Technical staff 1 2 3 4(C1) Other staff 1 2 3 4 Annual costs of above posts  Effort on project Year 1  Year 2  Year 3  TOTAL (A2) Research staff  SHAPE \* MERGEFORMAT % months1 2 3 4TOTAL A2 (B2) Technical staff 1 2 3 4 TOTAL B2 (C2) Other staff 1 2 3 4TOTAL C2  GRAND TOTAL (A2+B2+C2)  NICHSA has not in recent years funded research involving the use of animals Consumables (Please specify) Year 1  Year 2  Year 3  TOTAL Animals - Purchase (i) Intended source of supply (ii) Species and microbiological quality (iii) Number required (iv) Purchase price per animal Animals - maintenance  Subtotal annual costs  Consumables etc (continued) (Please specify) Year 1  Year 2  Year 3  TOTAL  Subtotal annual costs  Travel and subsistenceNumber ofMode ofFare/FeeTotalDestination and purpose (see notes)JourneysDaysTransportMileageSubsistence (i) Within the UK (ii) Overseas  Total annual costs (i) + (ii) Year 1Year 2Year 3TOTAL Exceptional items: Detail items applied for  TOTAL  Total annual costs Year 1Year 2Year 3 NICHSA does not usually support the cost of equipment Equipment Description of items and country of manufactureExpiry date of quotationLikely delivery dateBasic price Import duty  VAT  TOTAL 1 2 3 4 5 6 7 8  Annual cost of Above ItemsYear 1Year 2Year 3Year 41 2 3 4 5 6 7 Total annual cost  Curriculum vitae of applicant (please complete for each applicant) Surname: Forenames: Date of birth: Degree, etc (subject, class, University and date): Posts held (with dates). Please identify tenure and source of funding of present post: Recent publications as well as papers and press: 25. Supplementary information. Please indicate all grants which you or any member of your current research team have received from NICHSA in the last ten years. Please provide a brief summary of the results which arose from the use of these grants. Please state whether your request for funding is for the continuation of existing research or whether the project has been, or is currently being, funded from other sources. 26. Are there any commercial companies involved or in partnership in relation to this research? Yes/No If yes, please give full details on a separate sheet including the potential gain, the names of the Directors of the commercial company and the projected timescale to market. Any other relevant information would be appreciated. Please return one copy of this application by e-mail to cdevlin@nichsa.com and one copy by post with all relevant signatures to: Research Assistant Northern Ireland Chest Heart & Stroke 21 Dublin Road Belfast BT2 7HB Closing Date Friday 5th December 2008     Title of investigation Lead applicant Ref 200 PAGE   DATE \@ "dd/MM/yy" 09/06/08  FILENAME \p O:\Application forms research grants\Application Form 2008\NICHS Grant application form (June 08).doc Page  PAGE 13 of  NUMPAGES 13 : Ref: : +,G r  2 F Z y   x y ²tj```U`j`j``U`U`hg6CJOJQJhgCJOJQJhfCJOJQJhf5CJOJQJhg5CJOJQJhfCJOJQJ&jhfCJOJQJUmHnHuhgCJOJQJhchg5CJOJQJaJhchgCJaJhn@CJaJ(jhchgCJUaJmHnHuhghcjhcUmHnHu!,G  $$Ifa$ 9r $a$$a$gd#v-..    ! 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