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APPLICATION FORM

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    APPLICATION FORM APPLICATION FORM Document Transcript

    • APPLICATION FORM Kids Cancer Care Foundation of Alberta RESEARCH EQUIPMENT AWARD TITLE: INVESTIGATOR: Revised March 2009
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    • KIDS CANCER CARE FOUNDATION RESEARCH EQUIPMENT AWARD FUNDING APPLICATION GUIDELINES AND PRINCIPLES DO NOT INCLUDE THIS SECTION WITH YOUR APPLICATION 1. The Kids Cancer Care Foundation, through donations received from patients, relatives, friends and others, provides funding in support of pediatric oncology research. Because the funds are generated in Southern Alberta, research support is intended primarily for the community of researchers in this district. 2. The intent of this funding mechanism is to support and facilitate the purchase of essential research equipment, and by doing so to promote linkages between fundamental laboratory investigation and clinical or diagnostic applications or cancer prevention. Priority will be given to funding requests for equipment with clear relevance to pediatric oncology. A deadline in November for receipt of applications for funding will normally apply. In the event that funds in this category are not fully expended during the regular competition, it will be possible to apply at other times until available funds are depleted. Please contact the KCCFA office for further details. 3. Ethics, biosafety and/or animal care approval must be in place before funds are released on an approved study. 4. Funding available through this award mechanism will be limited to a maximum of $50,000 per year. This amount is intended to provide the full or partial costs for one or more equipment items in one or multiple laboratories. In the event that a needed equipment item costs more than $50,000, the application must clarify how remaining funds needed for purchase will be obtained. 5. Where an equipment item is funded by the KCCFA and the item is to be located at the University of Calgary, the Tom Baker Cancer Centre or the Alberta Children’s Hospital, arrangements must be made before the initiation of the project for the management of the funds. 6. A report to the KCCFA on the effectiveness of the instrument in achieving its stated objectives must be filed one year after purchase and installation. These reports allow the Foundation to assess the effectiveness of its funding programs. 7. Support from the Kids Cancer Care Foundation must be acknowledged in all reports or publications arising from KCCFA sponsored studies. 3
    • KIDS CANCER CARE FOUNDATION Research Equipment Award Funding Application REVIEW CRITERIA Statement of Objective(s) - Is the objective(s) of the proposal stated clearly - Is the critical nature of the requested equipment obvious Background Information and Literature Review - Is the information well organized and presented clearly and concisely - Has important and relevant material been overlooked Design - Is the experimental procedure specified (i.e. the collection and/or analysis of data, scientific research, demonstration with evaluation, preliminary development) Instrumentation - Are the instruments that are requested for the project fully justified; have alternative instruments been considered; are similar instruments available for sharing in nearby research settings Budgets - Is the proposed cost of the equipment item justified and supported by quotes; if several versions of the instrument are available from multiple manufacturers, has a good balance been obtained between cost and effectiveness; if multiple funding partners have been identified to share the cost of purchase of the equipment, are letters of support or understanding from the partners appended to the application - Is it clear that the requested instrument will be critical to the furtherance of a well identified pediatric oncology research program 4
    • KIDS CANCER CARE FOUNDATION Research Equipment Award Funding Application CHECKLIST FOR COMPLETION INCLUDE THIS PAGE WITH YOUR ORIGINAL APPLICATION ONLY Please check off the following list and include with application upon submission (Note: Indicate N/A if not applicable). Failure to complete these requirements will lead to immediate return of your proposal. [ ] The application has been submitted on a current form [ ] All required signatures have been obtained [ ] Ethics, biosafety and/or animal care approval has been applied for [ ] or appended [ ] to the application. If not, state why: (Approval must be in place before funds are released on an approved study.) [ ] Budget and summary pages for grants held and those that are pending are appended to the application. [ ] Quotations for equipment purchase costs and letters of support are appended to the application. [ ] Submit ONE ORIGINAL WITH SIGNATURES and an electronic copy of the complete application, by 5 PM, Wednesday, September 30, 2009 to: Christine Wandzura, M.S.M. Chief Executive Officer Kids Cancer Care Foundation of Alberta #302, 609 - 14th Street NW Calgary, Alberta T2N 2A1 Phone: 403-216-9210 Fax: 403-216-9215 e-mail: wandzura@kidscancercare.ab.ca 5
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    • KIDS CANCER CARE FOUNDATION Research Equipment Funding Application APPLICATION FOR FUNDING 1. Name of Principal Investigator: Position (Department/Faculty/University or Hospital): 2. Current Address of Principal Investigator: Telephone: E-mail address: 3. Proposed Project Title: 4. Has this project previously been before the KCCFA Research Committee? Yes [ ] No [ ]. If yes: Date: Title: 5. Location(s) or site(s) at which proposed equipment will be housed: 6. Name and address of Financial Officer who will administer funds if project is funded: 7. SIGNATURES The following signatures will be required. _______________________________________________________ Principal Investigator Date: _______________________________________________________ Division of Pediatric Oncology Director Date: _______________________________________________________ Department of Oncology or ACB Associate Director (Research) Date: _______________________________________________________ Dean of Faculty or representative Date: _______________________________________________________ Research Services Date: 8. If services are required in any other cancer facility department, the protocol must be circulated to the department director for endorsement. This will indicate that they concur with the protocol and that its requirements can be met within the department. Other responsible department (specify) Other responsible department (specify) 8
    • 9. BUDGET Duration of Award shall be one year Budget Category Item Cost/Item Subtotal Purchase Cost 1 Installation/Reno 2 Other 2 TOTAL AMOUNT REQUESTED 1 Cost of the requested equipment should be supported by quotations attached to the application. Multiple items may be listed on separate lines. 2 Costs associated with installation charges or needed renovation costs at the installation site may be requested, but must be justified on a separate page. In some cases costs of expendable supplies needed for calibration or trial operation of the equipment may be requested under the category of ‘other’, but these must also be justified. Budget allocation for the entire award may not exceed $50,000 in total. 9
    • 10. OUTLINE OF PROPOSED RESEARCH FOR WHICH EQUIPMENT IS REQUESTED (should not exceed two single-spaced pages excluding references. Nothing smaller than 12-point type should be used. Page reduction is not allowed.) Include immediate objective, methods to be employed and estimated duration of project. Indicate why the requested equipment will be critical to the project. Discuss choice of equipment model where alternatives are available. Discuss availability of similar instruments in nearby research locations. Discuss whether equipment will be shared with other investigators, and if so, append letters of collaboration or support. If funding in support of the equipment purchase is sought on a shared basis from other partners, append letters of support from these sources, or explain how parallel applications will proceed. PLEASE NOTE: Information provided in the grant application will be kept strictly confidential. (start here) 10
    • 11. PERSONAL DATA FORM Provide a completed and signed Personal Data form for the Principal Investigator. This form must be used; curriculum vitae will not be accepted. NAME OF APPLICANT: EDUCATION AND RESEARCH TRAINING Degree University/Institution Scientific Field Year ACADEMIC OR CLINICAL POSITIONS HELD Dates Institution Department Position PUBLICATIONS: Total number of publications in academic/medical career (excluding abstracts): List all papers published during the past five years. Earlier papers may be included if they are critical to the proposed study, but the total listing of papers should not exceed 3 pages. Title must be provided. Include papers accepted for publication. Do not include manuscripts or abstracts in preparation. A maximum of three manuscripts may be appended to this form. 11
    • 12. SOURCES OF SUPPORT - THIS PROJECT Please provide information about financial and other arrangements in place between the investigator(s) and the agencies (either private or public) funding this project. KCCFA will not provide duplicate funding for work supported by other agencies so please clarify how KCCFA resources will allow progress on work in the project that is distinct from that supported by other agencies. 1. Amount/yr $ Agency: Title of Project: Term of Grant: 2. Amount/yr $ Agency: Title of Project: Term of Grant: 3. Amount/yr $ Agency: Title of Project: Term of Grant: 13. NON-TECHNICAL SUMMARY The KCCFA often needs to supply information to the media or other lay organizations. Please provide a 100-150 word summary, in simple, non-technical language, which explains the rationale of the investigation and the relevance to cancer. (start here) 12
    • 14. SCIENTIFIC ABSTRACT & RELEVANCE TO PEDIATRIC ONCOLOGY In about 300 words, describe the objective and major elements of the strategy of the proposed research and its relevance to pediatric cancer. (start here) 15. APPENDICES Append quotations for the purchase cost of the requested equipment. Append letters of support from other users, if any, of the requested equipment. Append letters of support from other funding partners, if any. 13