Pilot grant application, version 2017
Pilot grant application
Version 2017
Stichting MS Research
P.O. Box 200
2250 AE Voorschoten
The Netherlands
E-mail : [email protected]
Tel.
: +31-71-5 600 500 or +31-71-5 600 508 (research coordinator)
Our project number: 17 –
MS
Please send an electronic version (Word-file) and 1 signed hard copy to the addresses above
Please use Arial 10, single line spacing
Extra attachments will not be accepted
Basic details
1
2
3
4
5
6
Name applicant, title(s)
Position
Institute
Department
Address, zip code, city
Telephone
E-mail
Title proposed project
English
Dutch
Brief summary of research
question and study design
(max. 300 words)
Lay summary (Dutch, max.
200 words)
Host institution
(if applicable)
Relevance for MS
Research proposal
7
Background & research
questions (max. 900 words,
max. 25 references)
Background
Hypothesis
Objectives
Pilot/preliminary data
if applicable
1
Pilot grant application, version 2017
8
9
10
11
12
13
Supplemental information
is not allowed
Study design & work plan
(max. 1000 words)
Planning subsequent years
(max. 200 and/or scheme)
Project group
(*fte involved in this project)
Embedding & cooperation
Relationship of this grant
proposal with other studies
financed by Stichting MS
Research
Has this grant proposal
been submitted to Stichting
MS Research previously?
If yes:
 What was the project
number of this proposal?
 What are the differences
between this and the
previously submitted
application?
Has this grant proposal
been submitted elsewhere?
Title(s) and name
yes/no
Human subjects, laboratory animals, biohazards
14
a.
b.
c.
d.
Will experiments be performed with:
Patient material
Healthy volunteers
yes/no
Patients
yes/no
If yes:
 Number of
volunteers/patients
 Type of research
 Does the proposed study
yes/no/requested
have the approval of a
commission regarding
experimental subjects?
Experimental animals
Use of experimental animals
yes/no
If yes:
 Kind of animals
 Number of animals needed
per year
 Nature of intervention
 Justification for the number
of animals required
 Does the proposed study
yes/no/requested
have the approval of a
commission regarding
experimental animals?
Brain material
Use of brain material
yes/no
Biological risks
Recombinant DNA
yes/no
If yes:
 Class
Radiation (wave and/or
yes/no
particle)
Radioactive isotopes
yes/no
Pathogenic micro-organisms
yes/no
2
Discipline
Employed by
Fte*
Pilot grant application, version 2017
Are required grants, permits
and facilities available?
yes/no
Finances and justification
15
16
Justification
Personnel, expertise,
discipline and time frame
Materials and/or patients
Other
Financial support from sources other than Stichting MS Research:
Own institute
Others
Personnel and budget requested **
17
18
Personnel
Function
Lump sum category
(delete whichever
is not applicable)
Fte
Amount of months
Costs (€)
Personnel
Materials/patients
Other
Total costs (€)
Scientific staff
Technical staff
PhD student/ scientific personnel
Non-scientific personnel level 1/ level 2
Project leader
Responsible administrator of
organisation
Signatures
19
Name
Date
Signature
Head of MS centre or Department
Name
Date
Signature
** According to the grant directives (version 2017)
3
Pilot grant application, version 2017
Addendum
Justification for the requirement of experimental animals *
21
a.
b.
c.
What are the reasons that this research…
…cannot be performed without experimental
animals (Replacement)?
…cannot be performed with fewer animals
(Reduction) or with less distress and discomfort
for the animals (Refinement)?
…cannot be performed with a lower species of
animals?
Justification for the requirement of EAE animal models *
22
What are the reasons that this research
requires the use of an EAE-animal model?
* If the grant proposal does not require experimental animals, this addendum can be deleted from the application
4