Research Support Grant

RESEARCH SUPPORT GRANT

APPLICATION FORM

RESEARCH SUPPORT GRANT

APPLICATION FORM ver2.0

This application form should be used for applications to Moorfields Eye Charity (MEC) where the total value of the actual request is less than £15,000 and the purpose of the request falls within the remit of the scheme.

Please use the Guidance Notes when completing the Application Form. The Guidance Notes provide more detailed advice about the scope of the scheme and what information is required in each section of the application form.

This scheme is to provide additional support to research which is currently funded (or very recently completed), to help maximise the outputs and impact of the research and increase likelihood of securing future external funding, This scheme is not intended to support avoidable short falls in funding or as a substitute where funds are available from other funding sources accessible to the researcher, including current grants, departmental or institutional funds.
Please ensure that all Annexes are completed
ANNEX A / Research support grant budget (excel file)
ANNEX B / Institutional research finance sign off
ANNEX C / Institutional / Research & Development sign off

COMPLETED APPLICATION FORMS MUST BE SUBMITTED, VIA EMAIL, TO

For any queries regarding your application please contact:

Dr Ailish Murray

Grants Manager, Moorfields Eye Charity

162 City Road | London | EC1V 2PD

Telephone: 020 7566 263

RSG/05/2015/VER12.0 2

RESEARCH SUPPORT GRANT

APPLICATION FORM

Section 1: Application summary Details

Q1. PRINCIPAL APPLICANT (Title / Name)
CO-APPLICANT (Title / Name) / Conditions apply - please refer to guidance notes
Q2. PROPOSAL TITLE (max 20 words)
Q3. START DATE (dd/mm/yyyy)
Q4. DURATION (months)
Q5. BUDGET SUMMARY / (a) Amount requested in this application / £
(b) Amount secured/to be secured from other source(s) / £
(c) Total Proposal Cost / £
Q6. HOST INSTITUTION / Moorfields Eye Hospital / UCL Institute of Ophthalmology
Q7. APPLICATION CATEGORY (Select one: please refer to guidelines)
Conference attendance / Dissemination costs / Access to service / facility
Publication costs / Small item(s) of equipment / Bridging funds for salary / stipend
Q8. AREA OF RESEARCH (please select area(s) that relates to the largest theme(s) of the proposal/research)
AMD / ☐ / Corneal / ocular surface disease / Community health / rehabilitation / patient support
Diabetic retinopathy / Glaucoma / Lens / cataract
Neuro-ophthalmology / optic neuropathies / Ocular cancer / Paediatrics
Ocular inflammatory diseases / Ocular motility / visual processing
Genetics / Inherited eye disorders / Retinal / Vitreo-retinal
Q9. JOINT MEH/IoO RESEARCH STRATEGY (please select one from (a) and (b) as applicable)
(a) Disease / Glaucoma / AMD / Diabetic retinopathy / Inherited eye disease / rare diseases
(b) Treatment / approach / Cell therapy / Informatics / Imaging / Gene therapy
Other (max 100 words) / please refer to guidance notes before completing

Section 2: Summary of proposal

Q1. SUMMARY OF PROPOSAL FOR SCIENTIFICALLY QUALIFIED ASSESSORS
To include purpose of funding and as applicable key research question(s), aims and objectives and potential outputs/impact. Max 150 words
Q2. SUMMARY FOR LAY READERS
To include, in a form comprehensible to a lay readership, purpose of funding and as applicable key research question(s), aims and objectives and potential outputs/impact Max 150 words
Q3. SECURING FURTHER FUNDING
To include details of how this additional support will enable future/further funding to be secured. Max 150 words
Q4. STRATEGIC FIT AND ENHANCEMENT OF RESEARCH AND/OR CLINICAL PRACTICE Max 150 words

Section 3: Principal applicant details and CV

In total this section must not exceed 3 sides of A4

Q1. CONTACT INFORMATION
Name and Title
Current post(s) (include employer name)
Address (department name and location)
Email address / Contact telephone number
Time spent on research (hrs per week) / Time spent on this grant (hrs per week)
Q2. PREVIOUS POSTS HELD (most recent first, maximum 5 entries)
Date from mm/yyyy / Date to mm/yyyy / Position / Organisation
Q3. EDUCATION AND TRAINING (most recent first, maximum 5 entries)
Date awarded mm/yyyy / Qualification / Subject / Organisation
Q4. GRANT APPLICATIONS TO SPECIAL TRUSTEES OR MOORFIELDS EYE CHARITY
(a) Awarded grants
Please list grants (most recent first) held in the last five years or any key prior grants. State title of project, role on the grant (e.g. PI, Co-PI), amount awarded, start/end dates and grant application number if known
(b) Unsuccessful applications
Please list applications in the last five years which were not awarded. State title of project, role on the grant (e.g. PI, Co-PI), amount requested and grant application number if known.
Q5. AWARDED GRANTS FROM OTHER FUNDING AGENCIES
Please list grants (most recent first) held in the last five years or any key prior grants. State name of awarding body, title of project, role on the grant (e.g. PI, Co-PI), amount awarded, and start/end dates.
Q6. PUBLICATIONS
Please list all (or key) publications from the last five years including original research publications and other scholarly contributions. Publications should be in chronological order with the most recent first. Maximum 1 side of A4

Section 4: Related Grants AND Applications

DETAILS OF APPLICATIONS TO AND AWARDS FROM FUNDING BODIES WITH FINANCIAL INPUT TO THIS PROJECT
Please include (for each application / award as relevant)
·  Name of funding body
·  Title of project and brief description of how the grant relates to the current application (max 100 words)
·  Total value of award and value of the contribution to work related to this application
·  Start/end dates / expected date of outcome (for submitted applications)

Section 5: Details of research and support requested

OUTLINE THE PURPOSE AND RATIONALE FOR THE SUPPORT REQUESTED Max 1000 words excluding references
For All applications:
·  Budget justification: this must be included as part of this section and must directly correlate to the budget completed as part of Section 6 / Annex A. See guidelines for additional information.
·  Images/figures/schematics may be embedded in the text or submitted as part of an appendix (maximum 1 side of A4) to this section.
·  References – give full citation including title, journal title and list all authors (use of el al is only appropriate where there are >10 authors)
For the details requested under each category, please click on the category name to link to the additional information at the end of the application form
Conference attendance
Dissemination costs / Access to service / facility
Publication costs / Small items of equipment
Bridging funds for salary / stipend

Section 6: Budget Details

The excel file ‘ANNEX A – RESEARCH SUPPORT GRANT BUDGET’ must be completed and submitted with the completed grant application. Please refer to guidance notes when completing this section. All costs must be approved by an appropriate authority at MEH or/and UCL IoO.
All costs must be justified with respect to the details in the current proposal and be incorporated, clearly, into Section 5: Details of research and support requested

Section 7: Additional information

Q1. Ethical approval (Note: applicants may be asked for additional details and/or to provide the necessary documents)
Does this work/ the project on which this proposal is based require ethical approval (either NHS and/or Home Office)? / Yes / No
Has the project on which this proposal is based been submitted for ethical approval or considered to be covered by existing ethical approval? / Yes / No
If YES, by whom and when the ethics of the project were approved (include relevant reference number(s)).
If NO, by whom and when will the ethics of the project be considered
Q2. Intellectual Property (IP) / Commercialisation
Will the proposed research use technology, materials or other invention that, as far as you are aware, are subject to any patents or other forms of intellectual property protection. If YES, give details (max 200 words) / Yes / No
Is the proposed research, in whole or part, subject to any agreements with commercial, academic or other organisation? If YES, give details (max 200 words) / Yes / No
Is there any potential for patents or commercially exploitable results from this research? If YES, give details (max 200 words) / Yes / No
If any potentially commercially exploitable results may be based upon tissues or samples derived from human participants, please confirm that there has been / will be appropriate informed consent for such use / Yes / No
If this research is successful will it provide e.g. new tools, drugs, biological materials, methods of treatment etc. that add value to eye health through a product, drug, vaccine etc. that should be protected because it will make money for the owner? If YES, please describe what this added value is (max 200 words)
Q3.. DATA MANAGEMENT AND SHARING Where appropriate, detail (a) your plans for data management, curation and storage (b) your policy for sharing data with others, including the management and prioritisation of access to data (c) your strategy for current and future communication with user communities and (d) any ethical considerations (max 200 words)

Section 8: Principal Applicant Sign Off

By signing this section, the Principal Applicant, confirms that he/she has complied with the instructions for completing and submitting this application and if the application is funded he/she will agree to the terms, conditions and processes of Moorfields Eye Charity.
Q1. CONSULTANCIES, EQUITIES AND DIRECTORSHIPS
Do you have consultancies or any equity holdings in, or directorships of, companies or other organisations that might pose a conflict of interest to the current application? If YES, give details (max 100 words) / Yes / No
Q2. PRINCIPAL APPLICANT SIGN OFF DETAILS
Name (print)
Signature
Date (dd/mm/yyyy)

ANNEX B: Institutional research finance sign off

We, the undersigned, confirm approval for submission of this application on the basis of the costs outlined in the attached application.
NOTE 1: This Annex should only be signed by the institution who will administer the award.
NOTE 2: Finance representatives are advised to retain a copy of this Annex for their own records as confirmation of approval may be requested by the Charity office
MOORFIELDS RESEARCH FINANCE REPRESENTATIVE DETAILS
Name (print)
Date (dd/mm/yyyy)
Have you reviewed Annex A - Budget (excel file) for this application? (delete one) / Yes / No
Do you approve this application? (delete one) / Yes / No
UCL INSTITUTE OF OPHTHALMOLOGY RESEARCH FINANCE REPRESENTATIVE DETAILS
Name (print)
Date (dd/mm/yyyy)
Have you reviewed Annex A - Budget (excel file) for this application? (delete one) / Yes / No
Do you approve this application? (delete one) / Yes / No

ANNEX C: institutional / research development sign off

We, the undersigned, confirm approval for submission of this application on the basis of the costs outlined in the attached application We indicate below any conditions attached to our approval. We understand that if this application for funding is successful, the principal host institution (as named in Section 1) will be required to confirm acceptance of Moorfields Eye Charity terms, conditions and reporting processes. We agree, where we represent collaborate institutions, to provide in a timely fashion, any information required by Moorfields Eye Charity or the principal host institution.
UCL INSTITUTE OF OPHTHALMOLOGY RESEARCH OFFICE
Name / Signature
Date (dd/mm/yyyy)
Has this application been approved by the Director of UCL Institute of Ophthalmology / Nominated deputy on the RAF? (delete one) / Yes / No
Comments
MOORFIELDS R&D OFFICE
Name / Signature
Date (dd/mm/yyyy)
(1) If the current application is a supplement to an current grant/study please answer the following:
(a) Was the original application considered by RAC/RMC? (delete one) / Yes / No
(b) Is the project still covered by any necessary approvals? (delete one) / Yes / No
(2) If the current application is NOT a supplement to a current grant/study, are all necessary approvals in place? (delete one) / Yes / No
Do you approve this application? (delete one) / Yes / No
Comments
MOORFIELDS RESEARCH & DEVELOPMENT DIRECTOR / NOMINATED DEPUTY
Name / Signature
Date (dd/mm/yyyy)
Do you approve this application? (delete one) / Yes / No
Comments
This appendix is for reference only and can be deleted from the final application form

Appendix: additional guidance notes for completing section 5

For each category, applicants should articulate the rationale for the request and provide justification for the level of funding requested. Details should include:

Conference attendance

·  conference name, start/end date, location, purpose of the conference

·  brief background of the underlying research area on which the research to be presented is based (include general background and researcher’s work)

·  details of what will be presented including the abstract of the poster / oral presentation

·  details of potential benefit / impact / outcomes from the conference attendance

·  Costs: (a) breakdown and justification of costs requested (b) details (breakdown) of any costs already secured in support of the conference attendance

back to Section 5

Dissemination costs

·  the event name, start/end date and location

·  details of the purpose of the event, target audience, potential impact and expected outcomes

·  brief background of the underlying research area on which the event is based

·  details of what will be presented / discussed including list of speakers / presenters

·  outline of if/how feedback will be collected and how it will be used/disseminated further

·  Costs: (a) breakdown and justification of costs requested (b) details (breakdown) of any costs already secured or potential ‘income’ e.g. registration fees in support of the event

back to Section 5

Access to service / facility

·  summary of progress to date on the research relevant to this request

·  list of publications relating to the original award(s), indicating in bold those publications directly relating to the request

·  details of the research / analysis that will be completed and reasons why the additional funds are needed at this time and were not secured under the original award / elsewhere

·  outline of potential outcomes and how the additional funds will enhance the activities being carried out under the original award(s)