DEBRA International / Registered Charity No: ZVR 932762489

DEBRA International

Application form for a funding extension to a

current research grant

NB: This form is for extensions to current grants for a maximum of one year only. All other applications should use the ‘Application Form – Research grant’.
(A)APPLICANT
Applicant details
Title: Prof / Dr / Surname / Forename(s)
Phone number / E-mail address / Position held by Applicant
Research institution
Research location of Lead Applicant
Department / Research institution
Full official postal address / Location(s) of project
(if being carried out at sites other than solely the Lead Applicant’s institution)
(B)PROPOSED INVESTIGATION
Research/ Clinical trial overview
Currentproject
Title
DEBRA Grant reference
Abstract of the proposed additional research to be carried out
(100 words maximum)
Proposed new end date / Proposed duration of the extension
(max. 12 months)
MM / YYYY / ... months
Details of planned project extension
Summary of progress on project to date
This should reflect progress to date in relation to project objectives and deliverables in original application. It should also note any areas where objectives have not been met, or progress is not on target for completion.(2000 words max plus figures).
Only if a progress report has been submitted within 1 month (30 days) prior to this application, may the progress report be appended instead.
Reasons for requesting extension
Indicate what added value the proposed additional work will provide to the project overall.
(200 words max)
Proposed research and methods to be employed
(1500 words max plus figures)
Ethical and regulatory issues
Human patients
Does the extension request involve a clinical study or in any other way involve participation of people with EB? (surveys or clinical trials) / ( ) Yes
( ) No
If so – what provision is made for protecting patient confidentiality?
If project results will be based upon tissues or samples derived from human participants, please confirm that there has been appropriate informed consent for such use. / ( ) Yes
( ) No
Has ethical/ institutional approval (IRB) for the clinical study/ trial been obtained? (Funding for relevant parts of research proposal/ clinical study cannot be released until such approval has been obtained: DEBRA may request evidence of such approval at any time).
Has any required national/international regulatory approval for the clinical study/ trial been obtained, or applied for yet?
Have discussions with regulators (e.g. EMA, FDA) taken place?
Please include a copy/ copies of the relevant document(s) if already available
Use of animals
Does the work proposed involve the use of protected animals in regulated procedures, or for protected species under the relevant legislation for the country/ies in which the research will be undertaken? / ( ) Yes
( ) No
If so – what species?
( ) Mouse
( ) Rat
( ) Zebrafish
( ) Dog
( ) Primate
( ) Other
How many animals?
……….
What consideration has been given to use alternatives to animals, and the ‘3R’ (to reduce or replace animal use, and to refine the research to minimise animal suffering)?
Are any of the procedures of substantial severity? / ( ) Yes
( ) No
Has/ have a license/s from the relevant authority been obtained yet for this work?
Please include a copy/ copies of the licence/permission document(s)
Intellectual property and commercial considerations
To be completed in discussion with your technology transfer office
Note any current commercial affiliations for Lead Applicant and Co-Applicant groups (e.g. staff, board or scientific adviser whether remunerated or unremunerated), and any current or recent research collaborations with commercial companies
What intellectual property (IP), including know-how, if any, could arise from this project?
(200 words max)
If this application involves the development of pre-existing intellectual property, whether belonging to the PI, or co-applicant(s) or collaborators, or provided as gifts or through any contract or agreement by other individuals, public or commercial organisations (consider, as a non-comprehensive list, that such intellectual property could include patented and non-patented technologies/research materials (e.g. mouse models, reagents, antibodies, cell lines etc.), then please:
  1. confirm that the Applicant and Co-Applicants have the required rights to work on the technologies (core and delivery) that will be used in this project.
/ ( ) Yes
( ) No
  1. Provide details of any existing agreements (commercial or academic), rights and obligations with/to third parties. Please list here, and append documents.(200 words max)

Include or attach relevant documents
  1. Provide contact details for the person at your institution responsible for the development and exploitation of intellectual property.

(C)ADDITIONAL FUNDING REQUESTED
Category / Additional Costs*
Scientific staff assistance
Include employer’s ‘on costs’ for each position. PI salary is not normally awarded.Salary for academic or clinical staff should be appropriate to experience required.
Technical/ Other assistance
Include employer’s ‘on costs’ for each position. Salary for academic or clinical staff should be appropriate to experience required.
Materials and Consumables
any individual items costing less than € 2500 ex-VAT
Apparatus and Equipment
any individual items costing more than € 2500 ex-VAT
Animals and Food
Details of animal experiments should be provided in detail together with permission of relevant national authority/ies (see Section (B) Proposed investigation - Animal research)
Other expenses
e.g. travel to collaborating laboratories.
NB: The funding of attendance at meetings or conferences cannot be met from the grant, unless the researcher will be presenting work funded by the grant.
DEBRA will fund actual costs of open-access publication of results, up to 1 year after completion of the grant, subject to a maximum of €5000 in total for the total period of the grant including any extension.
TOTAL

* please use same currency as in current grant

(D)REFEREES
Referees
You may suggest up to three referees. There is no guarantee, however, that they will be asked to review your application.
(please duplicate rows as needed)
Title / Forename / Surname
Expertise
Department / Institution
Telephone (incl. country code)
E-mail
Title / Forename / Surname
Expertise
Department / Institution
Telephone (incl. country code)
E-mail
Conflicts of interest
Please list those research groups or individual researchers you do not wish to review your proposal and state the reason why.
(please duplicate rows as needed)
Title / Forename / Surname
Department / Institution
Reason (200 words max)
Title / Forename / Surname
Department / Institution
Reason (200 words max)
(E)INSTITUTIONAL ADMINISTRATION APPROVAL
Head of Department/Institution
Title / Forename / Surname
“I confirm that, if approved for funding, the work will be accommodated and administered in the Department/ Institution.”
( ) Yes
Head of Department / Institution (SIGNATURE) / Date
Administrative Authority Member
Title / Forename / Surname
“I confirm that, if approved for funding, the Institution will administer the grant and invoice DEBRA quarterly in arrears for reimbursement.”
( ) Yes
Administrative Authority Member (SIGNATURE) / Date

DEBRA International Application form –Grant ExtensionJan 2016page 1 / 7