STANDARD QUESTIONNAIRE FOR OPEN LABPROGRAMME APPLICATIONS

(Please fit your text into the given spaces)

Type of collaboration:

Please tick the appropriate box(select box and choose Add Text in the mouse right button menu):

Small molecule Target Tool Other (please specify)

TuberculosisMalariaKinetoplastidsShigellosis

Participant details(complete all the data if there are more than one applicants)
Name(s) / Position(s)
Institution(s)
Contact Address(es)
E-mail(s) / Phone(s)
The evaluation outcome and related documents will be communicated by e-mail in .pdf format. Should you/your institution need a communication by post with original signature please indicate it in the box below.
Grants or Admin officer contact (name and e-mail address)
Project Title (fit your text in this given space/do not enlarge space)

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Executive Summary (fit your text in the given space)
Problem Statement (fit your text in the given space)
State of the art (fit your text in the given space)
Literature references relevant to the proposed work(fit your text in the given space)
Work Plan description (fit your text in the given space)
Work Package 1 - Title, site, timelines
WP objective and tasks description:
Work Package 2 - Title, site, timelines
WP objective and tasks description:
Work Package n - Title, site, timelines
WP objective and tasks description:
Project milestones that define key decision points and/or the success of the project(fit your text in the given space)
M1 -
Planned month (from project start):
M2 -
Planned month (from project start):
Mn -
Planned month (from project start):
Experience and expertise relevant to carry out the proposal including publications (fit your text in the given space)
Funding needed for the project
Use the project budget chart in last page
Resources to be committed by your group at home, in-kind or without fund request (estimated number of FTE’s, consumables, others) (fit your text in the given space)
What do you envisage GSK´s contribution to the project will be? (in kind, not funded by the Foundation)(fit your text in the given space)
Does your Institution (or somebody else) have IP protection on the idea?
Does your Institution find it acceptable to allocate all IP generated along the collaboration to WIPO Re:Search(See: Guiding principles of WIPO Re:search)
*You may attach only graphics and figures on separated pages

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Gantt Chart (see example below as reference)

MONTH
# WP / WP (short) name / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / Site
WP1*
WPn*
* Work Package numbers– matching the Work Plan described above
FTEs (fundedby OL)
Name FTE 1
Name FTE 2

Gantt Chart example

MONTH
# WP / WP (short) name / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / Site
WP1 / WP1 title / HomeName
WP2 / WP2 title / GSK DDW
WP3 / WP3 title / GSK DDW
FTEs (fundedby OL)
NameSurname

Project budget – funds requested to TCOLF

BUDGET
(for OL funding) / Description of costs to be funded / Eligiblecosts
Personnelcosts / GBP / (Number of months and experience level for each funded scientist) / Maximum personnel costs funded will be of:
  • Technician: £37.696/year
  • Degree: £41.165/year
  • PhD: £50.870/year
  • PhD with >10 years post doctoral experience: £76.087/year
Salary will be calculated deducting employer costs (social security contributions, life insurance if provided, etc) from this amount.
Operations / GBP / E.g. administrative costs, courier & shipping of materials, checkups, if needed
Travel / GBP / Travel to/from Home Institution location, if needed
Number of trips and reference rates: Project Review and Approval Process
Consumables / GBP / Lab supplies at the home institution ONLY, if any
Research services / GBP / Other research costs, e.g. subcontracting/CRO, if any
Other costs (specify) / GBP / Dissemination related expenses (conference fees, travel to conferences, publication costs), other costs if any.
Subtotal (Institution) / GBP
Accommodation / Number of months in Tres Cantos for each funded scientist: ___ / Accommodation during the stay in GSK DDW will be provided and paid by the TCOLF external supplier Relocations, provided that the researcher relocates to one of the flats administered in Tres Cantos.

Refer to theProject Review and Approval Process document for additional information on eligible costs.

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