Read the Guidelines Before Completing This Form

For office use only:

Reference nr. FG______/2015

Acronym

Project Proposal Clinical Grant

Deadline: 01:00 pm on 12th of May 2015

CONFIDENTIAL

Read the Guidelines before completing this form

Submit the electronic format at [email protected]

Project Proposal Clinical Grant 1 For office use only:

Acronym

General Information

PROJECT TITLE Project Title (MAX 150 CHARACTERS) ACRONYM Project Acronym (MAX 14 CHARACTERS)

PRINCIPAL INVESTIGATOR Name and surname of the Principal Investigator

HOST INSTITUTION Host Institution of the Principal Investigator

APPLICANT (ONE CHOICE)  SINGLE APPLICANT  CONSORTIUM

CONSORTIUM PARTNERS Partners’ name and Institution

 Experimental Clinical research (ie new therapies, palliative care)

TOPICS (ONE CHOICE)  Observational Clinical research (ie biomarkers, diagnostic and prognostic

(SELECT THE PROPOSAL studies) TOPIC)  Epidemiologic studies

 National Registries set up

 New application

RE-APPLICATION  Revised application – previous application acronym and year: ______

 Previous funded applicant – funded project acronym:______

PROJECT DURATION ______months (MAX 36 MONTHS)

AMOUNT REQUESTED (€) ______Euro

Legal Representative Principal Investigator

…………………………… ……………………………..

Signature and stamp Signature

Acronym

Section I: Project Information

SCIENTIFIC ABSTRACT (max 2.500 characters)

Describe rationale, broad objectives, project design and methods, anticipated output

BACKGROUND & RATIONALE (max 3.000 characters)

Describe background and rationale of the project

GENERAL OBJECTIVES (max 2.000 characters)

Describe projects aims

METHODOLOGY (max 8.000 characters)

Describe the methodologies adopted and the study design

PRELIMINARY DATA (max 4.000 characters)

Report preliminary data collected

ADVANCEMENT BEYOND THE STATE OF THE ART (max 1.000 characters)

Describe the advancements brought by the proposal to the ALS field

RELEVANCE TO ARISLA (max 1.000 characters)

Describe how the goals of the proposal fit with AriSLA Foundation aims

Acronym

Section II: Work Plan

CONSORTIUM COMPLEMENTARITIES AND SYNERGIES (max 2.500 characters)

Describe the reasons of complementarities and synergies of all participants

REFERENCES: Report references (max 20 references)

Report project references

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 (to be compiled only by a consortium)

WP1 DESCRIBE HOW THE MULTICENTRE PROJECT WILL BE MANAGED (max 3.500 characters)

Indicate strategies aimed at: - monitoring activities of all centres; - 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...

WP2 METHODS (max 3.000 characters)

Describe methods used to perform the WP activities Project Proposal Clinical Grant 4 For office use only:

Acronym

WP2 PARTNER CONTRIBUTION (max 2.000 characters)

Specify who is doing what

Work Package 3: Title

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 PARTNER CONTRIBUTION (max 2.000 characters)

Work Package n: Title

(Please copy, paste and fill one section FOR EACH WP)

WPN DESCRIBE AIMS AND STRUCTURE (max 2.500 characters)

WPn description

Acronym

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 PARTNER CONTRIBUTION (max 2.000 characters)

Acronym

II.2 GANTT Chart

1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 Month 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 WP n – Partner n….

II.3 List of Deliverables and months

WP n - Task n Nr of Deliverable Title Month of Delivery D1 1, 2, 6… D2

Acronym

Section III: Impact on ALS (max 3.000 characters)

Describe the impact of expected results on ALS disease and evaluate which aspects of the research could have IP rights protection.

Acronym

Section IV: Budget

IV.1 Overall Budget Table

REQUESTED TO ARISLA

Expressed in Euro

Materials, Sub- Other Overheads Personnel Supplies, contracting TOTAL expenses F=(A+B+C+D+)*0,0 (A) Equipment (Services) A+B+C+D +F (D) 5 (B) (C) Principal Investigator

Partner 1

Partner 2

Partner 3

Partner 4

Partner 5

TOTAL requested to AriSLA

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.

Acronym

IV.2 Cost Justification: Principal Investigator

REQUESTED TO ARISLA

Expressed in Euro

Year 1 Year 2 Year 3 TOTAL

Personnel

Materials, Supplies, Equipment

Sub-contracting (Services)

Other expenses

Overheads

PERSONNEL TABLE (requested to= AriSLA)

Number Total Months Average cost per month TOTAL (A) (B) (C) (D = B*C)

Post Doc

PhD student

Graduate

Other (*)

(*) Please specify

PERSONNEL TABLE (other personnel working on the project)

Number Total Months Granted by

Principal Investigator

Post Doc

PhD student

Graduate

Other (*)

(*) Please specify

Acronym

PERSONNEL: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

MATERIALS, SUPPLIES, EQUIPMENT: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

SUB-CONTRACTING (SERVICES): Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

OTHER EXPENSES: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

Acronym

IV.3 Cost Justification Partner n (please copy, paste number and fill one section FOR EACH PARTNER)

REQUESTED TO ARISLA

Expressed in Euro

Year 1 Year 2 Year 3 TOTAL

Personnel

Materials, Supplies, Equipment

Sub-contracting (Services)

Other expenses

Overheads

= PERSONNEL TABLE (requested to AriSLA)

Number Total Months Average cost per month TOTAL (A) (B) (C) (D = B*C)

Post Doc

PhD student

Graduate

Other (*)

(*) Please specify

PERSONNEL TABLE (other personnel working on the project)

Number Total Months Granted by

Group Leader (project partner)

Post Doc

PhD student

Graduate

Other (*)

Acronym

(*) Please specify

PERSONNEL: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

MATERIALS, SUPPLIES, EQUIPMENT: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

SUB-CONTRACTING (SERVICES): Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

OTHER EXPENSES: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)

Acronym

Section V: Applicant

 SINGLE APPLICANT  CONSORTIUM

V.1 Principal Investigator

PRINCIPAL INVESTIGATOR

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 RESEARCH EXPERIENCE AND A BRIEF DESCRIPTION OF THE HOST INSTITUTION (max 3.000 characters)

Acronym

SELECTED PUBLICATIONS RELEVANT TO THE PROPOSAL (max 300 characters each)

Five more recent publications

Five more important publications

Five more relevant publications

PATENTS OWNED BY THE APPLICANT, if any

Acronym

V.2 Partner 1 (please copy, paste, number and fill one section FOR EACH PARTNER)

CO-INVESTIGATOR 1

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 RELEVANT TO THE PROPOSAL (max 300 characters each)

Five more recent publications

Five more important publications

Acronym

Five more relevant publications

PATENTS OWNED BY THE APPLICANT, if any

Acronym

Section VI: 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

Acronym

Section VII: Revision Process

PROPOSED REVIEWERS (Name and contact details)

Name Surname

Institution E-mail

Last year of Specify the collaboration collaborating (if any) Partner

Name Surname

Institution E-mail

Last year of Specify the collaboration collaborating (if any) Partner

UNDESIRABLE REVIEWER (Name and contact details)

Name Surname

Institution E-mail

Justify your choice

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Section VIII: 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 Principal Investigator

………………………………………………… ………………………………………………… Timbro e Firma Firma

Acronym

Section IX: Check list Item Completed (Please tick) General Information (in pdf)  Project title and Acronym  Principal Investigator and Host Institution  Applicant  Consortium Partners  Topics  Re-application  Project Duration  Amount requested to AriSLA  Section I - Project Information Scientific abstract  Background and Rationale  General objectives  Methodology  Preliminary data  Advancement beyond the state of the art  Relevance to AriSLA  Section II - Work Plan Consortium complementarities  References  Workpackage 1  Workpackages 2-n  GANTT Chart  List of Deliverables and months  Section III - Transferability and proximity to cure  Section IV - Budget Overall Budget  Cost justification - Principal Investigator  Cost justification - Partners  Section V - Applicant Principal Investigator information  Co-Investigator(s) information  Section VI - Lay summary  Section VII - Revision Process 

Acronym

Section VIII - Privacy Statement (pdf) 

SAVE THE FILE WITH THE ACRONYM NAME AND SEND IT BY E-MAIL TO [email protected]

WITHIN May 12th, 2015 at 01:00 pm

Project Proposal Clinical Grant 22