This form is intended for research concept submission by investigators in Japan. Your proposal will be reviewed by a team of internal experts and ranked with other proposals that Medtronic receives during the review period. If your research proposal is acceptedfor funding, your institution will be asked to submit relevant documents and enter into a research agreementwith Medtronic Japan Co., Ltd. within 30 days.

All submission forms, proposals, and attachments must be completed in English. Non-English submission forms and attachments will not be considered for review.

Intellectual Property Warning:

By submitting this form, you are acknowledging that you have either secured your intellectual property rights for your research concept, or you are not interested in any intellectual property that is described in this proposal.

By submitting this form, you also acknowledge that you have secured the right to submit this form.

When completed, please e-mail the form in PDF format as an attachment to . The subject for the submission e-mail should read “ERI research proposal submission form”. You may also attach any previous publications, patents, and/or other applicable documents to the proposed study.

RESEARCH PROPOSAL

Section A: General Request Information
Request Date: / (MM/DD/YYYY)
Submission Category / SPN
Section B: Investigator/Institution Information
Investigator Name(English): / MD PhD
(Japanese漢字):
Investigator Title:
Investigator Birth Date: / // (mm/dd/yyyy)
Investigator Phone:
Investigator Email:
Institution Name:
Address1:
Address2:
Ward/City:
Prefecture:
Postal Code:
Section C: Support Requested
Amount of Medtronic Funding requested (max of 1 million JPY): JPY
Is funding being applied for/received from other sources/organizations for the proposed study? No Yes
If yes, please specify the other sources of support requested and/or received for this study:
Section D: Short Description of theProposal
* Please describe the significance of the proposal within 200 words.
Section E: Summary of Proposed Study Information
*Please describe the summary of your proposed study in this section briefly. Section Eshould not exceed one page.
Study Title:
Study Objective(s)
Describe what question(s) will be answered by this study:
Describe the patient population that would benefit from the results of the study, if translated to human applications:
Short summary ofthe proposed study design and sample/treatment groups: (e.g., number of animals, number of samples per condition, treatment conditions, etc.) Please provide further details in Section F.
Estimate study duration (ten months maximum):
Estimate study start date:
Estimate study end date:
Describe relevance to Medtronic’s therapies and/or diagnostics:
Publication Plan: (Intent to publish results, target journals, target submission dates)
Section F: Detailed Proposed Study Information
*Please describe the background and the study methods (including materials) in detail in maximum of one page.
Background of the study design:
Study materials and methods (in numbered list format):
1.
2.
3.
4.
5.
Section G: Investigator’s Background
*Please provide the following information in this section:
①Educational background and degrees earned;②Research experience;③Honors and awards received related to the proposed study; and④List of publications related to the proposed study.
①Educational background and degrees earned:
Academic Institution / Major/Field of study / Degree earned / Year
②Research experience:
③Honors and awards received related to the proposed study:
④List of publications related to the proposed study:
Section H: Itemized Budget
*Please describe the items needed for the research as well as the associated cost.
Item / Unit price [JPY] / Quantity / Total price [JPY]
Total
Survey
Where did you hear about the grant?
Medtronic Japan website From your research institution From internet search
In a scientific journal Please specify: others:
If you have any comments regarding the grant or the submission form itself, please comment below:

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