3CTN Adolescent and Young Adult (AYA)

PROJECT CONCEPT SUBMISSION 2015

PROJECT TITLE
LEAD INSTITUTION ADMINISTRATIVE AUTHORITY
e.g., Vice-President, Research, CEO, or COO who is legally able to bind the institution.
Surname / Given Names
Institution / Department
Address: Street, Building, Wing or Room
City / Telephone / Extension
Email Address
Email Address
Signature Date
______
By way of signature, I attest to: Reviewing and supporting this Proposal to the 3CTN initiative; and reviewing and understanding the 2015AYA Project Concept Guidelines.
LEAD INVESTIGATOR
Surname / Given Names
Institution / Department
Address: Street, Building, Wing or Room
City / Telephone / Extension
Email Address
Email Address
Signature Date
______
By way of signature, I attest to reviewing the AYA Project Concept Guidelines and supporting this submission to the 3CTN Program.
CO-INVESTIGATOR
Surname / Given Names
Institution / Department
Address: Street, Building, Wing or Room
City / Telephone / Extension
Email Address
Email Address
Signature Date
______
By way of signature, I attest to reviewing the AYA Project ConceptGuidelines and supporting this submission to the 3CTN Program.
CO-INVESTIGATOR
Surname / Given Names
Institution / Department
Address: Street, Building, Wing or Room
City / Telephone / Extension
Email Address
Email Address
Signature Date
______
By way of signature, I attest to reviewing the AYA Project Concept Guidelines and supporting this submission to the 3CTN Program.
CO-INVESTIGATOR
Surname / Given Names
Institution / Department
Address: Street, Building, Wing or Room
City / Telephone / Extension
Email Address
Email Address
Signature Date
______
By way of signature, I attest to reviewing the AYA Project Concept Guidelines and supporting this submission to the 3CTN Program.
DETAILED PROJECT PROPOSAL
Please attach Proposal
Priority will be given to ongoing, multi-disciplinary, multi-centre clinical trials reflecting the Adolescent and Young Adult population, and meeting the criteria as per guidelines.
Attach a project proposal that includes:
  • AYA Proposal Concept request:
  • Background and rational
  • Aims and objectives
  • Methods
  • Milestones and Deliverables
  • An estimate of resources needed, including potential sources for ability to fund requested resources*
*3CTN will fund the workshop. The funding for the proposal will be from relevant other sources.
TEXT LIMIT: maximum 2 pages, single spaced (Times New Roman, 12 pt. font), 1 inch margins all around.

AYA Project Concept – Application Form, V.2, March 10, 2015 1