Internal: Merck, Sharpe & Dohme Corporation Funds

Translational Research

APPLICATION FORM

One-year grantTwo-year grant

IDENTIFICATION
APPLICANT LAST NAME: / APPLICANT FIRST NAME:
FACULTY: / DEPT/SCHOOL:
APPLICANT CONTACT INFORMATION
TELEPHONE: / EMAIL ADDRESS:
CO-APPLICANTS
CO-APPLICANT LAST NAME/FIRST NAME: / FACULTY: / DEPT/SCHOOL: / AFFILIATE (JGH, DOUGLAS, MNI, ST. MARY’S):
Enter 1 or 2 Quebec Government Clarder codes:
Code 1:Please SelectAnatomy - 03SNT011Anesthesia - 03SNT012Biochemistry - 03SNT013Biomedical Engineering and Biochemical EngineeringCardiology - 03SNT016Cell Biology - 03SNT014Chiropractic - 03SNT000Dentistry - 03SNT027Dermatology - 03SNT018Dietetics and Nutrition - 03SNT019Endocrinology - 03SNT020Epidemiology and Biostatistics - 03SNT049Family Medicine - 03SNT028General code medical sciences - 03SNT999Genetics - 03SNT022Geriatrics-Gerontology - 03SNT023Health Administration - 03SNT010Hematology - 03SNT024Immunology - 03SNT025Microbiology - 03SNT026Molecular Biology - 03SNT015Nephrology - 03SNT032Urology - 03SNT047 Code 2:Please SelectNuclear Medicine - 03SNT029Nursing - 03SNT009Nutrition - 03SNG019Obstetrics and Gynecology - 03SNT033Occupational Therapy - 03SNT002Oncology - 03SNT034Ophthalmology - 03SNT035Optometry - 03SNT036Orthopedics - 03SNT005Pathology - 03SNT038Pediatrics - 03SNT044Pharmacology - 03SNT040Pharmacy - 03SNT039Physiatry - 03SNT006Physical Engineering - 03SNG012Physiology - 03SNT041Physiotherapy - 03SNT007Pneumology - 03SNT042Preventive and Community Medicine - 03SNT030Psychiatry - 03SNT043Radiology - 03SNT045Rheumatology - 03SNT046Speech-Language Pathology and Audiology - 03SNT037Virology - 03SNT048
Select Research Site
Primary Research Site:SelectConstance-Lethbridge Rehabilitation CentreDouglas HospitalJewish General HospitalJewish Rehabilitation HospitalLake Shore General HospitalMcGill UniversityMontreal Chest Hospital - MCHMontreal Chest Institute - MCIMontreal Children's HospitalMontreal General HospitalMontreal Neurological Hospital - MNHMontreal Neurological Institute - MNIOther: fiels work, CLSC, etc.Royal Victoria HospitalShriners HospitalSt Mary's Hospital McGill Building:
Are there additional research sites? Yes No
If yes:
ETHICS CERTIFICATION:Do you require ethics for this project? Please check “yes” or “no
ANIMAL
Yes No / BIOHAZARD
Yes No
HUMAN
Yes No / RADIOISOTOPE
Yes No
BUDGET DETAILS / AMOUNT $
Salaries for support staff & research personnel
Stipends for graduate students & postdoctoral fellows
Material supplies & incidentals
Other (please specify)
GRAND TOTAL

BUDGET JUSTIFICATION

Please use the space provided below for budget justification.Indicate clearly if you are including a MITACS-supported partnership.Failure to provide budget justification may result in your application being disqualified.
APPLICATION COMPONENT – PLEASE ATTACH THE FOLLOWING
1)Summary of the proposed research, including reference to prioritized disease area (max. 250 words)
2)Description of research proposal (include rationale/hypotheses (including brief literature review), specific aims, experimental plan, milestones, and path to translational outcomes:
-1 year awards: max 4 pages (including figures and references)
-2 year awards: max 6 pages (including figures and references)
3)Canadian Common CV (CIHR format)
SIGNATURES
The application form must be signed by the Applicant and the Departmental Chair, and uploaded to UReview.
1)SIGNATURE OF APPLICANT:
2)THE CHAIR MUST APPROVE THIS APPLICATION
CHAIR’S SIGNATURE: / PLEASE PRINT:

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