application form for pmc 2015 final form for pmc 2017... · application"form"...

9
PMC PUMP PRIME GRANT Call for Biomedical Research 2017 1 PERSONALISED MEDICINE CONSORTIUM (PMC) PMC PUMP PRIME GRANT Call for biomedical research 2017 Application form This application form must be completed in English and sent electronically, at the latest on 15 October 2016, to: pmc@ibbl.lu Name of the Research project: ................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... Leader name: ................................................................................................................................................................... ................................................................................................................................................................... ................................................................................................................................................................... ...................................................................................................................................................................

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Page 1: Application form for PMC 2015 final form for PMC 2017... · Application"form" ThisapplicationformmustbecompletedinEnglishandsent electronically,atthelateston"15 October20 16,to:pmc@ibbl.lu

PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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PERSONALISED  MEDICINE  CONSORTIUM  (PMC)    

PMC PUMP PRIME GRANT Call  for  biomedical  research  2017  

Application  form  

This  application  form  must  be  completed  in  English  and  sent  

electronically,  at  the  latest  on  15 October  2016,  to:  [email protected]  

Name  of  the  Research  project:    ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................    

Leader  name:    ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................    

Page 2: Application form for PMC 2015 final form for PMC 2017... · Application"form" ThisapplicationformmustbecompletedinEnglishandsent electronically,atthelateston"15 October20 16,to:pmc@ibbl.lu

PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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1. Institutions & Investigators

Investigator  1  

Name:    .......................................................................................................................................................    Surname:    ..................................................................................................................................................    Nationality:    ..............................................................................................................................................    

Address:    ...................................................................................................................................................    

Tel:    ............................................................................................................................................................    E-­‐Mail:    ......................................................................................................................................................    

Institution  (name  and  address)  

 ...................................................................................................................................................................    

Investigator 2  

Name:    .......................................................................................................................................................    Surname:    ..................................................................................................................................................    Nationality:    ..............................................................................................................................................    

Address:    ...................................................................................................................................................    

Tel:    ............................................................................................................................................................    E-­‐Mail:    ......................................................................................................................................................    

Institution  (name  and  address)  

 ...................................................................................................................................................................    

Investigator 3  

Name:    .......................................................................................................................................................    Surname:    ..................................................................................................................................................    Nationality:    ..............................................................................................................................................    Address:    ...................................................................................................................................................    

Tel:    ............................................................................................................................................................    E-­‐Mail:    ......................................................................................................................................................    

Institution  (name  and  address)    ...................................................................................................................................................................    

Add  as  many  investigators or subcontractors  as  needed  on  the  provided  separate  sheet  (page  9)  

Select the partnering funding institutions: (at least 2 of these institutions are mandatory)

IBBL LIH LCSB

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PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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2. Project  presentation

2.1:  Summary  :  (0.5  page  maximum)    ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................    

2.2:  Scientific  background  of  the  project  :  (2 pages  maximum)    Includes  clearly  stated  hypothesis,  state-of-the-art,  work  plan  to  be  undertaken,  why  pump  priming  is  needed,   expected   deliverables,   start   &   end   dates,   timeline, names of collaborators involved, expertise of the partners.

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PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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 ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................     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 ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................     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 ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................     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PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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2.3:  Cost:  Please complete the following table to show a detailed breakdown of the funds requested. Please ensure all collaborators are consulted to make sure all expenses are included. This funding can be used for consumables, external sample analyses, data collection, inter-institution costs (at cost price), market research, literature reviews, pilot studies led by clinician-researchers. It cannot be used for existing staffing, existing infrastructure, already funded project components or as a “bridge fund” for researchers).

Iteme.g. DNA extractions

Unit sizee.g. per kit

Cost per unit (EUR) Number of Units Total cost (EUR) e.g. 300 e.g. 15 e.g. 4500

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PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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2.4   :   Multi-institutional  dimension  of  the  project  :  (0.5  page  maximum)    Includes  demonstration  of  true  interdisciplinary  (between  LIH,  LCSB,  IBBL,  hospitals  and  other  biomedical   institutions   addressing   the   research   question),   value   added   to   science   through   the   partnership    ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................    

2.5  :  Impact  of  the  project  :  (1  page  maximum)  Includes  clinical  impact,  economic  impact  on  Luxembourg,  preliminary  expectations…    ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................    

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PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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2.6  :  Next  steps  of  the  project:  (0.5  page  maximum)  Includes:  clearly  articulated  next  steps  following  the  pump  priming  award,  future  joint  research  likely  to  accrue  from  the  collaboration    ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................      ...................................................................................................................................................................    

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PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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3. Contact

Angela  Hogan  IBBL  INTEGRATED  BIOBANK  OF  LUXEMBOURG  6,  rue  Nicolas  Ernest  Barblé,  L-­‐1210,  Luxembourg  E-­‐Mail  :  [email protected]    

*************  

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PMC PUMP PRIME GRANT Call for Biomedical Research 2017

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Additional  Investigators or Subcontractors  

Investigator:  

Name:    ..................................................................................................................................................    Surname:    ..................................................................................................................................................    Nationality:    ..............................................................................................................................................    Address:    ...................................................................................................................................................    

Tel:    ............................................................................................................................................................    E-­‐Mail:    ......................................................................................................................................................    

Institution  (name  and  address)    ...................................................................................................................................................................    

Investigator:  

Name:    .......................................................................................................................................................    Surname:    ..................................................................................................................................................    Nationality:    ..............................................................................................................................................    Address:    ...................................................................................................................................................    

Tel:    ............................................................................................................................................................    E-­‐Mail:    ......................................................................................................................................................    

Institution  (name  and  address)    ...................................................................................................................................................................    

Investigator:  

Name:    .......................................................................................................................................................    Surname:    ..................................................................................................................................................    Nationality:    ..............................................................................................................................................    Address:    ...................................................................................................................................................    

Tel:    ............................................................................................................................................................    E-­‐Mail:    ......................................................................................................................................................    

Institution  (name  and  address)    ...................................................................................................................................................................