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: Great Ormond Street Hospital Childrens Charity
Clinical Research Starter Grants
Preliminary Application Form
Great Ormond Street Hospital Childrens Charity (GOSHCC) is committed to supporting high quality research with the potential to improve the health and well-being of children at Great Ormond Street Hospital (GOSH), through better diagnosis, treatment, improved care and cures. Our niche is the rapid translation of research for patient benefit. Our detailed research strategy can be found on our website: HYPERLINK "http://www.gosh.org/research" http://www.gosh.org/research
Please ensure that you read the guidance notes which accompany this form prior to completing it. All questions need to be completed using size 11 font and standard page margins (2.5cm). Applications which do not conform to the formatting guidelines will not be accepted.
Please email an electronic copy of your completed form (and direct any queries, as appropriate) to HYPERLINK "mailto:research@gosh.org" research@gosh.o r g . T e l . : 0 2 0 7 2 3 9 3 2 0 8 . T h e c o m p l e t e d f o r m a n d w e t - i n k c o p y o f t h e s i g n a t u r e s h e e t m u s t b e s u b m i t t e d b y F r i d a y 1 9 D e c e m b e r 2 0 1 4 , 5 p m .
F o r G O S H C C u s e o n l y A p p l i c a t i o n R e f e r e n c e F O R M T E X T
A p p l i c a t i o n S u m m a r y P r o j e c t T i t l e
( s h o r t t i t l e o f p r o p o s e d r e s e a r c h ) F O R M T E X T D u r a t i o n o f F u n d i n g ( m o n t h s ) F O R M T E X T T o t a l F u n d i n g R e q u e s t e d ( s ) F O R M T E X T P r o p o s e d S t a r t D a t e ( d d / m m / y y y y )
A l l p r o j e c t s m u s t c o m m e n c e f r o m 1 s t A u g u s t 2 0 1 5 o n w a r d s F O R M T E X T H o s t I n s t i t u t i o n ( G O S H ; I C H ; I C S ) F O R M T E X T
L e a d A p p l i c a n t C o n t a c t D e t a i l s ( O f f i c i a l A d d r e s s f o r C o r r e s p o n d e n c e )
( L e a d A p p l i c a n t s m u s t b e r e s e a r c h a c t i v e G O S H c l i n i c i a n s b a s e d a t e i t h e r t h e I C H , G O S H o r I C S ) P o s i t i o n H e l d F O R M T E X T T i t l e F O R M T E X T F i r s t N a m e F O R M T E X T S u r n a m e F O R M T E X T C o n t a c t A d d r e s s F O R M T E X T T e l e p h o n e F O R M T E X T M o b i l e F O R M T E X T E m a i l F O R M T E X T P l e a s e c o n f i r m t h a t a C V h a s b e e n a t t a c h e d t o t h e a p p l i c a t i o n F O R M T E X T C o - a p p l i c a n t / C o l l a b o r a t o r D e t a i l s P o s i t i o n H e l d F O R M T E X T T i t l e F O R M T E X T F i r s t N a m e F O R M T E X T S u r n a m e F O R M T E X T E m a i l F O R M T E X T D e p a r t m e n t F O R M T E X T C o - a p p l i c a n t o r C o l l a b o r a t o r F O R M T E X T P l e a s e p r o v i d e d e t a i l s o n t h e n a t u r e o f t h e p a r t n e r s h i p o r c o l l a b o r a t i o n a n d h o w i t w i l l e n h a n c e t h e p r o j e c t F O R M T E X T
P r o p o s e d I n v e s t i g a t i o n T h i s s e c t i o n s h o u l d i n c l u d e b a c k g r o u n d t o t h e r esearch, the main aims and objectives, and brief practical details. It should explain how the data gathered will move the research into the next stage or support the development of a research question (1500 words max, with an additional page for references, any diagrams must be incorporated into this space). FORMTEXT
I m p a c t o f t h e R e s e a r c h P l e a s e d i s c u s s t h e f e a s i b i l i t y t o t r a n s l a t e t h e r e s e a r c h i n t o p a t i e n t b e n e f i t w i t h i n 5 - 1 0 y e a r s a n d t h e p o t e n t i a l i m p a c t o f t h e r e s e a r c h o n d i s e a s e s / i s s u e s t r e a t e d a t G O S H ( 3 0 0 w o r d s m a x ) . F O R M T E X T
L e v e r a g i n g F u r t h e r F u n d i n g P l e a s e d e s c r i b e h o w t h i s g r a n t w i l l b e u s e d t o l e v e r a g e f u r t h e r f u n d i n g , p a r t i c u l a r l y f r o m t h e N I H R . P l e a s e i n c l u d e d e t a i l s o f t h e t y p e s o f f u n d i n g s t r e a m s t h a t y o u e x p e c t t o a p p l y t o ( 2 0 0 w o r d s m a x ) . F O R M T E X T
F i n a n c i a l Support RequiredPlease provide a broad outline of expected costs. Do not add additional rows within the table. If the proposal is short listed, more detail will be required in the full application. Please allow ample time for the joint R&D office to review the financial support being requested as part of your application. All projects must commence from 1st August 2015 onwards.
Category
Name, Position, Grade, %FTE
2014/2015
()
2015/2016
()
2016/2017
()
2017/2018
()
TOTAL
Staff Salaries
SUBTOTAL - SALARIES
Consumables
Item
2014/2015
()
2015/2016
()
2016/2017
()
2017/2018
()
TOTAL
SUBTOTAL - CONSUMABLES
Equipment
Item
2014/2015
()
2015/2016
()
2016/2017
()
2017/2018
()
TOTAL
SUBTOTAL - EQUIPMENT
Additional Costs
Item
2014/2015
()
2015/2016
()
2016/2017
()
2017/2018
()
TOTAL
SUBTOTAL ADDITIONAL
2014/2015
()
2015/2016
()
2016/2017
()
2017/2018
()
TOTAL
TOTAL COST OF PROJECT
(TOTAL OF SUBTOTALS)
Brief Justification of Costs
Declarations and signaturesPlease print this page, have it authorised and return it by post to the address below.
Grants Officer
Great Ormond Street Hospital Childrens Charity
4th Floor, 40 Bernard Street
London WC1N 1LE
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T h e a p p l i c a t i o n f o r m a n d t h e w e t i n k D e c l a r a t i o n a n d S i g n a t u r e s s e c t i o n o f t h i s f o r m m u s t b e c o m p l e t e d a n d r e t u r n e d t o t h e C h a r i t y b y F r i d a y 1 9 D e c e m b e r 2 0 1 4 , 5 p m .
R & D n u m b e r : & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . .
T i t l e : & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . .
& & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . . .
L e a d a p p l i c a n t : & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & &
H o s t I n s t i t u t i o n : & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & & . I c o n f i r m t h a t a l l t h e i n f o r m a t i o n i n t h i s a p p l i c a t i o n i s c o r r e c t a n d t h a t I w i l l n o t i f y G r e a t O r m o n d S t r e e t H o s p i t a l C h i l d r e n s C h a r i t y o f a n y c h a n g e s .
S i g n e d : & & & & & & & & & & & & & & & & & & & D a t e : & & & & & & & & & & & & & . .
( L e a d a p p l i c a n t )
S i g n e d : & & & & & & & & & & & & & & & & & & & D a t e : & & & & & & & & & & & & & . .
( C o - a p p l i c a n t )
S i g n e d : & & & & & & & & & & & & & & & & & & & D a t e : & & & & & & & & & & & & & . .
( C o - a p p l i c a n t )
S i g n e d : & & & & & & & & & & & & & & & & & & & D a t e : & & & & & & & & & & & & & . .
( C l i n i c a l G e n e r a l M a n a g e r , u n i t / d e p a r t m e n t h e a d )
S i g n e d : & & & & & & & & & & & & & & & & & & & D a t e : & & & & & & & & & & & & & . .
( U n i t / D e p a r t m e n t h e a d )
S i g n e d : & & & & & & & & & & & & & & & & & & & D a t e : & & & & & & & & & & & & & . .
( D i r e c t o r o f F i n a n c e o r a u t h o r i s e d f i n a n c e o f f i c e r )
C u r r i c u l u m V i t a e t o b e c o m p l e t e d b y l e a d a p p l i c a n t a n d a n y o t h e r c o - a p p l i c a n t s . P l e a s e c o p y a n d p a s t e t e m p l a t e a s r e q u i r e d .
C U R R I C U L U M V I T A E :
F u l l N a m e
C u r r e n t P o s i t i o n F u l l J o b T i t l e : D a t e f r o m :
P r e v i o u s P o s t s H e l d D a t e f r o m : D a t e t o : P o s i t i o n : I n s t i t u t i o n
O t h e r F u n d i n g P l e a s e p r o v i d e d e t a i l s o n a l l o t h e r a w a r d s t h a t y o u c u r r e n t l y h o l d . P r i n c i p a l A p p l i c a n t F u n d i n g B o d y T o t a l s i z e o f a w a r d D a t e o f a w a r d S t a r t E n d
C u r r e n t P r o f e s s i o n a l A c t i v i t i e s D e t a i l s ( e . g . c o m m i t t e e s , e d i t o r i a l b o a r d s , m e m b e r o f p r o f e s s i o n a l b o d y )
P r i z e s a n d A w a r d s D a t e s D e t a i l s
P u b l i c a t i o n s U p t o 1 5 k e y p u b l i c a t i o n s
P l e a s e u s e t h e C V t e m p l a t e p r o v i d e d
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