For office use only:

Reference nr. FG_TR______/2015

Acronym

Project Proposal

Assistive Technology Grant

Deadline:01:00 pm on September 15th2015

CONFIDENTIAL

Read the Guidelines before completing this form

Submit the electronic format at

General Information

Project Title
(max 150 characters) / Project Title
Acronym (max 14 characters) / Project Acronym
SUBJECT / Name and surname of the Subject participating to the Call.In case of Partnership, the applicant of the Proposal should be the non profit entity.
Legal entity
Topics (one choice)
(select the proposal topic) / Devices or services for motricity
Devices or services for communication
Project duration (between 12 and 24 months) / ______months
Amount Requested (between 30.000€ and 300.000€) / ______Euro
keywords / List maximum 3 keywords referred to the project

Legal RepresentativeSubject

…………………………………………………………..

Signature and stampSignature

Section I:Project Information

Abstract (max 2.500 characters)

Describe background/rationale, broad objectives, project design and development, anticipated output.

Background and Rationale(max 3.000 characters)

Describe background and rationale of the project.

Objectives (max 2.000 characters)

Describe projects aims.

MaturityLevel of available technology(max 4.000 characters)

Describe the maturity of the technology required for the project and the features that make it such.

product or service development (max 8.000 characters)

Describe the developmental strategy adopted for the implementation, customization and validation of the new product/service proposed.

advancement beyond the state of the art(max 1.000 characters)

Describe the advancementsbrought by the proposal to the ALS patients and caregivers.

relevance to arisla (max 1.000 characters)

Describe how the goals of the proposal fit with AriSLA Foundation aims.

future development and project exploitation for patient community(max 2.000 characters)

Describe the Subject involvement in the project to ensure the exploitation of the product/service proposed.

Section II:Work Plan

subject complementarities and synergies (max 2.500 characters)

Describe the complementarities and synergies of all the Subject.

publications and other References: Report references (max 20 references)

Report project references.

II.1

Work Packages:present a detailed workplan, divided into work packages (WPs), following the logical phases of the project implementation

Work Package 1: Management and Project Coordination

WP1 Describehow the project will be managed(max 3.500 characters)

Indicate strategies aimed at:
-monitoring activities of all Subject;
-facilitating communication;
-promoting exchange of ideas and methodological approach;
-stimulating the analysis and the integration of results.

Work Package 2: Title

Start date (month) / End Date (month)

WP2 Describe Specific Aims and Structure (max 2.500 characters)

WP2 description

WP2 Tasks (max 3.000 characters)

Describe WP2 activities to be performed T1, T2...

WP2Methods (max 3.000 characters)

Describe methods used to perform the WP activities.

WP2 subject Contribution(max 2.000 characters)

Specify who is doing what

Work Package 3: Title

Start date (month) / End Date (month)

WP3 Describe Specific Aims and Structure (max 2.500 characters)

WP3 description

WP3 Tasks (max 3.000 characters)

Describe WP3 activities to be performed T1, T2...

WP3Methods (max 3.000 characters)

Describe methods used to perform the WP activities

WP3 subject Contribution(max 2.000 characters)

Specify who is doing what

Work Package n: Title

(Please copy, paste and fill one section FOR EACH WP)

Start date (month) / End Date (month)

WPn Describe Aims and Structure (max 2.500 characters)

WPn description

WPn Tasks (max 3.000 characters)

Describe WPn activities to be performed T1, T2...

WPnMethods (max 3.000 characters)

Describe methods used to perform the WP activities

WPn subject Contribution(max 2.000 characters)

Specify who is doing what

Project ProposalAssistive Technology Grant 1

For office use only:

Reference nr. FG_TR______/2015

Acronym

II.2GANTT Chart

Month / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24
WP n

II.3List of Deliverables and months

WP n - Task n / Nr of Deliverable / Title / Month of Delivery
D1 / 1, 2, 6…
D2

Project ProposalAssistive Technology Grant 1

For office use only:

Reference nr. FG_TR______/2015

Acronym

Section III:Impact on ALS

target beneficiary (max 1000 characters)

Describe and estimate the number of direct and indirect beneficiaries.

impact on patients and caregivers quality of life (max 1500 characters)

Describe how the product/service proposed will improve the QoL of ALS patients and their families.

project innovation(max 1500 characters)

1) Make a competitive analysis of the product/service proposed respect to the ALS devices on the market;
2) Describe the innovative features of the product/service proposed.

business model and economic sustainability (max 1500 characters)

1) Give information about the development of the project at the end of the AriSLA grant;
2) Define up to three key impact indicators for the evaluation of product/service success.

Section IV:Dissemination and Intellectual Property

(max 4000 characters)

1) Evaluate which aspects of the product/service proposed could have patent protection and describe the management of the intellectual property;
2) Describe the communication plan and include measures to provide open access to peer-reviewed scientific publications which might result from the project.

Section V:Budget

V.1 Overall Budget Table

Requested to AriSLA

Expressed in Euro

Personnel
(A) / Materials, Supplies, Equipment
(B) / Sub-contracting
(Services)
(C) / Other expenses
(D) / Overheads
E=(A+B+C+D+)*0,05 / TOTAL
A+B+C+D+E
Subject

Other Financial support

Specify all financial resources available in direct support of the research (max 3000 characters).

Please specify title and duration of the project. It is compulsory to indicate: the relative period; gross amount; granting agency; brief description of the project. If applicable, specify possible overlaps with the proposed project.

V.2 Cost Justification

Requested to AriSLA

Expressed in Euro

Year 1 / Year 2 / TOTAL
Personnel /
Materials, Supplies, Equipment
Sub-contracting (Services)
Other expenses
Overheads
TOTAL requested to AriSLA

Personnel Table (requested to AriSLA)

Role / Related WP / Months
(A) / Cost per month
(B) / TOTAL
(C = A*B)
Job title (e.g. clinician, engineer, technician, …)
…
…
…
TOTAL

Personnel Table(other personnel working on the project)

Role / Number / Total Months / Granted by
Job title
…
…
…
TOTAL

Personnel: Please describe the financial allocations foreseen in this cost category (max 1.500 characters)

Materials, supplies, equipment: Please describe the financial allocations foreseen in this cost category (max 1.500 characters)

Sub-contracting (Services): Please describe the financial allocations foreseen in this cost category (max 1.500 characters)

Other expenses: Please describe the financial allocations foreseen in this cost category (max 1.500 characters)

Section VI:Subject

VI.1 Applicant

Name / Surname
Title / Tel.
Mobile / E-mail

Legal Representative

Name / Surname
Tel. / Fax
E-mail / Web site

Host Institution (fill in complete Italian name)

Address
Zip Code / City / Country

CV, relevant experience and a brief description of the Host Institution (max 3.000 characters)

Selected publications or other materialrelevant to the proposal (max 300 characters each)

1.
2.
3.
4.
5.

patents owned by the applicant,if any

VI. 2 Subject 2

(please copy, paste, number and fill one section FOR EACH SUBJECT)

subject 2

Name / Surname
Tel. / Mobile
E-mail / Web site

Host Institution (fill in complete Italian name)

Address
Zip Code / City / Country

CV, relevant research experience and a brief description of the Host Institution (max 3.000 characters)

Selected publications (or other materials) relevant to the proposal (max 300 characters each)

1.
2.
3.
4.
5.

patents owned by the subject,if any

Section VII:Lay Summary

Lay Summary in English (max 2.500 characters)

Summarize the project using lay language.

Lay Summaryin Italiano (max 2.500 caratteri)

Riassumi il progetto in un linguaggio divulgativo

Section VIII:Revision Process

Proposed reviewers (Name and contact details)

1 / Name / Surname
Institution / E-mail
Last year of collaboration
(if any) / Specify the collaborating Partner
2 / Name / Surname
Institution / E-mail
Last year of collaboration
(if any) / Specify the collaborating Partner

Undesirable reviewer (Name and contact details)

Name / Surname
Institution / E-mail
Justifyyour choice

Section IX:Privacy Statement

INFORMATIVA

ai sensi dell’art. 13 del Decreto Legislativo 30 giugno 2003, n. 196

TUTELA DELLE PERSONE E DI ALTRI SOGGETTI RISPETTO AL TRATTAMENTO DI DATI PERSONALI

In relazione alle eventuali forme di collaborazione che si potrebbero instaurare fra la Fondazione AriSLA e il Vostro Ente, si informa che i dati personali - da Voi forniti - formeranno oggetto di trattamento.

Si informa in particolare che:

  1. le finalità del trattamento sono legate ad esigenze di tipo istruttorio ed operativo connesse al perseguimento degli scopi istituzionali della Fondazione e non implicano alcuna valutazione sul merito dell’iniziativa prospettata;
  2. il conferimento dei dati a Voi richiesti per le finalità di cui sopra ha natura facoltativa e non obbligatoria;
  3. l’eventuale diniego da parte Vostra a fornire i dati per il trattamento comporterà l’impossibilità per la Fondazione di valutare qualsiasi ipotesi di collaborazione con il Vostro Ente;
  4. il trattamento dei dati da Voi forniti potrà comportare la comunicazione e la diffusione dei medesimi nei limiti stabiliti dalla Legge;
  5. al Vostro Ente spettano i diritti previsti all’articolo 7 del Decreto Legislativo 30 giugno 2003, n. 196, di seguito riportato;
  6. il titolare del trattamento dei dati è la Fondazione AriSLA, con sede in Viale Ortles 22/4 - 20139 Milano; responsabile del trattamento dei dati personali è il Segretario Generale della medesima Fondazione AriSLA, Viale Ortles 22/4 - 20139 Milano.
  7. qualsiasi richiesta in ordine al trattamento stesso potrà essere inoltrata ai suddetto indirizzo.

CONSENSO

In relazione all'informativa trasmessa, si esprime il consenso previsto dall’art. 23 del Decreto Legislativo 30 giugno 2003, n. 196, al trattamento dei dati che concernono il nostro Ente da parte della Fondazione AriSLA nel perseguimento delle sue finalità istituzionali, connesse e strumentali, nonché alla comunicazione e alla diffusione dei dati stessi di cui al numero 4 della predetta informativa.

Per ricevuta informazione e consenso

AutorizzoNon Autorizzo

Data: ______

Denominazione dell’Ente
______
Rappresentante LegaleSubject
……………………………………………………………………………………………………
Timbro e FirmaFirma

Section X:Check list

Item / Completed (Please tick)
General Information(in pdf) / 
Project title and Acronym / 
Subject / 
Legal Entity / 
Topics / 
Project Duration / 
Amount requested / 
Keywords / 
Section I - Project Information
Abstract / 
Background and Rationale / 
Objectives / 
Maturity level of available technology / 
Product or Service development / 
Advancement beyond the state of the art / 
Relevance to AriSLA / 
Future development and project exploitation for patients community
Section II - Work Plan
Subject complementarities and synergies / 
Publication and other references / 
Workpackage 1 / 
Workpackages 2-n / 
GANTT Chart / 
List of Deliverables and months / 
Section III –Impact on ALS
Target beneficiary / 
Impact on patients and caregivers Quality of Life / 
Project innovation / 
Business Model and economic sustainability / 
Section IV –Dissemination and Intellectual Property / 
Section V - Budget
Overall Budget / 
Cost justification / 
Section VI–Subject
Applicant / 
Subject 2-n / 
Section VII - Lay summary / 
Section VIII - Revision Process / 
Section IX- Privacy Statement (pdf) / 
Section X – Check List / 

Save the File with the Acronym Name and Send it by E-mail to

Within September 15th, 2015 at 01:00 pm

Project ProposalAssistive Technology Grant 1