The Novo Nordisk
UK Research Foundation
Charity registration number: 1056410
Grant
Preliminary Application form
(Handwritten forms will NOT be accepted, please use font size 12)
The sole sponsor of The Novo Nordisk UK Research Foundation is Novo Nordisk Ltd.
Handwritten forms will NOT be accepted, please use font size 12. Answer all questions in this application form, inserting lines as required. If you have an queries regarding this application form please contact the Foundation on 01293 762009 or
1. Name of main applicant:
Appointment:
Place of work (with complete address):
Tel. Number:
Email:
2. Co-applicant(s) if any:
Name(s):
Appointment(s):
Place of work (if different from that of main applicant):
Tel:
Email:
3. Title of project (max. 20 words):
4. Amount requested:
Please give a breakdown of costs and where relevant include VAT.
(Maximum £12,000) TOTAL
5. Please summarise the project as a 250 word abstract to include top line
information on the following:
· aims
· background
· plan of investigation; please include justification of sample size and
recruitment plans where appropriate
· justification for the support requested
6. Other resources available to support this project:
7. Is Ethics Committee opinion necessary? YES/NO
If yes please give the current status of the ethics committee application:
Are relevant licences in place? YES/NO/NA
8. Can you confirm that all governance requirements (e.g. good clinical practice, research governance framework, safeguarding etc.,) will be complied with?
9. How might your research lead to patient benefit (max 100 words)?
10. Do your proposals include procedures to be carried out on animals in the UK under the Animals (Scientific Procedures) Act?
Yes (please answer questions 11 and 12) No (go to question 13)
11. Have the following necessary approvals been given by:
· The Home Office (in relation to personal, project and
establishment licences)?
· Animal Welfare and Ethical Review Body?
12. Do your proposals involve the use of animals or animal tissue outside the UK?
If your project involves the use of animals what would be the severity of the
procedures?
Please provide details of any moderate or severe procedures (max 250 words)
Why is animal use necessary? Are there any other possible approaches? (max 250 words)
Please justify the number of animals to be used per experiment, including details of any sample size calculation and/or statistical advice sought.
13. I confirm that the amount requested in this application has been assessed
to the best of my knowledge and will be as close to actual costs as possible.
Any salary scales have been confirmed by the relevant finance department.
I have met internal obligations and can confirm this is a legitimate application.
Where appropriate: I confirm that I have read this application and that if the
Grant is awarded, the work will be accommodated in this department.
Signature of applicant:……………………………………………………………………………
Date:
Signature of head of department: ……………………………………………………..
Name:
Date:
Name of department and institution:
14. Please indicate where you saw the Grant advertised.
15. Summary (one page) curriculum vitae and relevant publications of
the main applicants.
Please note that this document including CV’s will be securely stored for a maximum term of 18 months for unsuccessful applicants.
Please submit a hard copy of the signature page to: The Novo Nordisk UK Research Foundation, Foundation Administrator, 3 City Place, Beehive Ring Road, Gatwick, RH6 0PA.
2
October 2015