ADVOCACY FOR NEUROACANTHOCYTOSIS PATIENTS

Research Grant
Application

Name	
____________________________________________	

Project Title	
____________________________________________
____________________________________________	

Institution	
____________________________________________	

ADVOCACY FOR NEUROACANTHOCYTOSIS PATIENTS
Research Grant Application

Eligibility
The Advocacy for Neuroacanthocytosis Patients (AfNP) Grant Awards are provided as “seed monies” ($50,000) for new clinical or basic research projects that are directly related to understanding the neuroacanthocytosis diseases, in the hope that the results can be used to attract funding from other sources. Applicants must have an M.D. or a Ph.D. degree and already have a faculty appointment at an accredited medical school, university or research institute.  Applications from all countries are welcome.

Terms
The AfNP Grants conditions are published on the AfNP website www.naadvocacy.org “Grant Decision-Making Process” and are similar to those of the Wellcome Trust. http://www.wellcome.ac.uk/doc%5Fwtd004055.html .  Grants will support personnel (other than the Principal Investigator), supplies and equipment.   The award does NOT cover indirect costs. Applications must be made through an accredited medical school, university or research institute, which must agree to supply the clinical or laboratory facilities. Awards are paid in installments, contingent upon satisfactory progress as documented in progress reports submitted to AfNP.  All publications resulting from research funded by AfNP must acknowledge the Advocacy for Neuroacanthocytosis Patients and should be provided to AfNP when in-press.

Application
Completed proposals must be received by AfNP no later than January 15 2012, at 1700 GMT.  In addition, your proposal (including all supporting documents) must be submitted as a single electronic file in PDF file format.  Proposals should be completed on line and submitted via email.  Applicants who submit proposals via email are advised to verify receipt of same.  
1.	1.	An electronic version of the application form may be obtained/completed online at our website:  www.naadvocacy.org.  Contact Glenn Irvine glenn@naadvocacy.org for additional information.
2.	2.	Each proposal must be submitted electronically as a single file in PDF file format.  Paper copies will not be 
      accepted, nor will applications submitted in any file format other than PDF be accepted.
1.	3.	Submit to AfNP by the deadline an electronic copy of your application for funding.
Awards will be recommended by the Scientific Advisory Panel prior to formal approval by the AfNP.  Awardees will be notified in April  2012. 

Supporting Documents
Applications must be accompanied by a letter from the director and/or project supervisor of the department in which the work will be done, evaluating the significance of the research to be conducted and potential of the researcher.  Proposals involving the participation of human subjects must indicate any potential risks (physical or psychological).  Copies of the certified consent form and approval from the sponsoring Institutional Review Board (IRB) for the protection of human subjects in research must accompany the application.  ALL proposals for research involving use of animals must include statement certifying compliance with all applicable laws, and conformity with legislation and administrative directives in the country in which  the research will take place.  A completed application includes, in order, the following:
I.	I.	Administrative Information
II.	II.	Research and Training Plan Summary
III.	III.	Budget
IV.	IV.	Biographical Sketch
V.	V.	Other Research Support
VI.	VI.	Letter of Support
VII.	VII.	Research and Training Plan

Application for Research Grant

Section I - Administrative Information

Principal Investigator:		

Title or Position:	
Degrees:	

Institution:		

Department:		

Your Address at Institution:

	
Telephone:	
	
E-Mail:	
	
Fax:	

Type of Institution:
      Public Institution:      State      Local      Private Institution      Other:_________________________		

Full Title of Research Proposal:

		

Abbreviated Title of Research Proposal (also at top of each application page):

Dates of Proposed Project Period:	
Amount Requested for one year:	

Name / Title / Address / Telephone / Fax / E-mail of Person to Whom Checks Should be Mailed:
(person indicated is official signing for the applicant organization)

		

Terms and Conditions

The undersigned agree to: (1) acknowledge support from AfNP in any publication resulting from an award, (2) submit a final report within one month after the end of the support period, and supply copies of reprints or manuscripts supported by the award.

___________________________________________________________________	____________________
Signature of Principal Investigator							Date

___________________________________________________________________	____________________
Signature of Official Representing the Applicant Organization				Date

Abbreviated Title of Research Proposal:	

Section II - Research Plan Summary

Full Title of Application:

	

Abstract of Research Plan (do not exceed the space provided):

	

Lay Summary

	

Abbreviated Title of Research Proposal:	

Section III - Budget for 12-Month Grant Period

From:	
Through:					

Personnel	
Amount Requested					

Name, Official Title, Department	

Role on Project	

% Effort	

Salary	
Fringe Benefits	

Total	

	
Principal Investigator	

	

	

	

	

	

	

	

	

	

Subtotals	

			

Equipment (itemize):	

	

	

	

Supplies (itemize briefly by category):	

	

	

	

Other (itemize briefly by category):	

	

	

	

Total Direct Costs for Proposed Budget for 12-Month Grant Period	
					
Note:AfNP provides only direct costs for research support.  You may use additional pages if necessary.  You may include resources available to carry out research plan (not to exceed one [1] page).  Justify any unusual or large items or expenditures.

Abbreviated Title of Research Proposal:	

Section IV - Biographical Sketch

Please provide the following information for all key personnel.  A copy of this page should be completed for each individual.

Name
	
Position Title			

Education / Training (Begin with baccalaureate or other initial professional education, such as nursing.  Include postdoctoral training.)				

Institution and Location	
Degree
(if applicable)	
Year(s)	
Field of Study	

	

	

Research and Professional Experience: Concluding with present position, list, in chronological order, previous employment, experience, and honors.  Include present membership on any  public advisory committee.  List, in chronological order, the titles, all authors, and complete references to all publications during the past three years and representative earlier publications pertinent to this application.  If the list of publications in the last three years exceeds two pages, select the most pertinent publications.  Do not exceed TWO PAGES.

Note: An NIH format bio-sketch is acceptable.

Abbreviated Title of Research Proposal:	

Section V - Other Research Support

List all other research support of the principal investigator, including requests now being considered as well as any proposal which the principal investigator plans to submit to a  public health service, foundations, or other agencies, regardless of relevance to this application.  To be included also are current or pending contracts, Fellowship Awards, Research Career Awards and Training Grants.  Include support for this project received from sponsoring institution.  Amounts shown reflect total fund awarded or pending over the entire grant periods indicated in the final column.  Note:  Percent effort for all projects cannot exceed 100%.

There is no form page for other support.  Information on other support should be provided in the format shown below.  The sample is intended to provide guidance regarding the type and extent or information requested.

Format

Name of Individual
Active/Pending			

Project Number (Principal Investigator)
Source	
Dates of Approved/Proposed Project
Annual Direct Costs	
Percent Effort	

Title of Project (or subproject)			

The major goals of this project are...			

Overlap (summarized for each individual			

Sample

ANDERSON, R.R.

Active		 
2 R01 HL 00000-13 (Anderson)		                            3/1/98 - 2/28/99		              30%
NIH / NHLBI						$186,529
Chloride and Sodium Transport in Airway Epithelial Cells
The major goals of this project are to define the biochemistry of chloride and sodium transport in airway epithelial cells and clone gene(s) involved in transport.

5 R01 HL 00000-07 (Baker)				4/1/96 - 3/31/98			10%
NIH / NHLBI						$122,717
Ion Transport in Fetal Lung
The major goal of this project is to study chloride and sodium transport in normal and cystic fibrosis fetal lung.

Pending	DCB 95000 (Anderson)				12/01/97 - 11/30/99		20%
National Science Foundation				$43,123
Liposome Membrane Composition and Function

The major goals of this project are to define biochemical properties of liposome membrane components and maximize liposome uptake into cells.

Overlap	There is scientific overlap between aim 2 of NSF DCB 950000 and aim 4 of the application under consideration.  If both are funded, the budgets will be adjusted appropriately in conjunction with agency staff.	

Abbreviated Title of Research Proposal:  

Section VII - Research and Training Plan 

1.	Summary of specific aims (brief)*

1.	Background and significance (2 pages)*

1.	Preliminary studies, with figures*

1.	Methods, expected results, data analysis, interpretation and significance*

1.	Literature cited

1.	Consultant and collaborative arrangements (if applicable)

1.	IRB Certification/Protection of Human Subjects information (if applicable)

1.	Laboratory Animal Welfare information (if applicable)

*Cumulatively, items 1-4 may not exceed 10 pages of 12-point type. 

The review committee will be familiar with standard methodologies but critical experimental details must be provided.  Applications should be concise but complete.  Applications that do not conform to these specifications will not be reviewed.

Deadline:	January 15, 2012 at 1700 GMT  

Applicants may only submit proposals electronically via email as a single PDF file.

Return completed application to:

glenn @naadvocacy.org

Glenn Irvine
Advocacy for Neuroacanthocytosis Patients 
32 Launceston Place 
London W98 5RBVN
Tel +44 02(0) 7937 2938

The Advocacy for Neuroacanthocytosis Patients gratefully acknowledges the help of the Huntington’s Disease Society of America in creating this application form.