For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
Project Proposal
Assistive Technology Grant
Deadline: 01:00 pm on September 15th 2015
CONFIDENTIAL
Read the Guidelines before completing this form
Submit the electronic format at [email protected]
Project Proposal
Assistive Technology Grant
1
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
General Information
PROJECT TITLE
(MAX 150 CHARACTERS)
ACRONYM
(MAX 14 CHARACTERS)
SUBJECT
Project Title
Project Acronym
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 Representative
Subject
……………………………
……………………………..
Signature and stamp
Signature
Project Proposal
Assistive Technology Grant
2
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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.
MATURITY LEVEL 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 advancements brought 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.
Project Proposal
Assistive Technology Grant
3
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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 DESCRIBE HOW 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...
Project Proposal
Assistive Technology Grant
4
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
WP2 METHODS (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...
WP3 METHODS (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)
Project Proposal
END DATE (MONTH)
Assistive Technology Grant
5
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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...
WPN METHODS (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 Proposal
Assistive Technology Grant
6
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
II.2
GANTT 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
WP n
II.3
WP n - Task n
List of Deliverables and months
Nr of Deliverable
Month of Delivery
Title
D1
D2
Project Proposal
1, 2, 6…
Assistive Technology Grant
7
24
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.
Project Proposal
Assistive Technology Grant
8
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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.
Project Proposal
Assistive Technology Grant
9
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
Section V:
Budget
V.1 Overall Budget Table
REQUESTED TO ARISLA
Expressed in Euro
Personnel
(A)
Materials,
Supplies,
Equipment
Subcontracting
(Services)
(B)
(C)
Other
expenses
(D)
Overheads
TOTAL
E=(A+B+C+D+)*0,05
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.
Project Proposal
Assistive Technology Grant
10
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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
Cost per month
TOTAL
(A)
(B)
(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
Project Proposal
Assistive Technology Grant
11
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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)
Project Proposal
Assistive Technology Grant
12
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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)
Project Proposal
Assistive Technology Grant
13
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
SELECTED PUBLICATIONS OR OTHER MATERIAL RELEVANT TO THE PROPOSAL (max 300 characters each)
1.
2.
3.
4.
5.
PATENTS OWNED BY THE APPLICANT, if any
Project Proposal
Assistive Technology Grant
14
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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.
Project Proposal
Assistive Technology Grant
15
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
PATENTS OWNED BY THE SUBJECT, if any
Project Proposal
Assistive Technology Grant
16
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
Section VII:
Lay Summary
LAY SUMMARY IN ENGLISH (max 2.500 characters)
Summarize the project using lay language.
LAY SUMMARY IN ITALIANO (max 2.500 caratteri)
Riassumi il progetto in un linguaggio divulgativo
Project Proposal
Assistive Technology Grant
17
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
Section VIII:
Revision Process
PROPOSED REVIEWERS (Name and contact details)
Name
Surname
Institution
E-mail
Last year of
collaboration
(if any)
Specify the
collaborating
Partner
Name
Surname
Institution
E-mail
Last year of
collaboration
Specify the
collaborating
Partner
1
2
(if any)
UNDESIRABLE REVIEWER (Name and contact details)
Name
Surname
Institution
E-mail
Justify your choice
Project Proposal
Assistive Technology Grant
18
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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 Legale
Subject
…………………………………………………
…………………………………………………
Timbro e Firma
Firma
Project Proposal
Assistive Technology Grant
19
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym
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

Project Proposal
Assistive Technology Grant
20
For office use only:
Reference nr.
FG_TR ______ /2015
Acronym

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 [email protected]
WITHIN SEPTEMBER 15TH, 2015 at 01:00 pm
Project Proposal
Assistive Technology Grant
21