For Further Information Contact the CHS

CANADIAN HEMOPHILIA SOCIETY - NOVO NORDISK CANADA

PSYCHOSOCIAL RESEARCH PROGRAM

- 2015 RESEARCH GRANT APPLICATION FORM -

Following the acceptance of your letter of intent by the CHS, please send this completed application, electronically (using a font size of 10 point), by January 8, 2015 to: [email protected] AND One (1) original paper copy, including signatures , by January 8, 2016 to: Canadian Hemophilia Society 666 Sherbrooke Street West, Suite 301, Montreal, QC H3A 1E7

The grant, to be used mainly for salary support, normally commences April 1 and is for one year with a maximum of $20,000 per project. The primary intent of this program is to offer one or two $20,000 research grants, to a maximum of $40,000 for one year. Depending upon the number and quality of applications, funding for different amounts may be possible, as is the offering of more than one grant, within the allotted total budget stated above.

For further information contact the CHS: E-mail: [email protected] Telephone: 1 800 668-2686

All applicants must consult the general criteria at www.hemophilia.ca/en/research/chs---novo- nordisk-psychosocial-research-program/general-criteria and the general conditions at www.hemophilia.ca/en/research/chs---novo-nordisk-psychosocial-research-program/general- conditions before completing this application.

IMPORTANT! Use the arrow keys to navigate between fields, or the TAB key to move to the next field; or click on a field with your mouse to enter data. Hit the enter/return key ONLY when you have multiple entries to include within a field. To ensure that all graphic lines and boxes on this form are displayed, select print layout on the view menu.

1. I NF O RM AT I O N ABO UT P RI NCI P AL I NV E S T I G AT O R : (as at time of application) Last name First name Initial

Title Dr. Ms. Mr. Prof.

Institution Department

Citizenship (refer to eligibility criteria) Street address (include street type, and any floor, suite or room numbers to ensure precise addressing) City Province Postal code

Telephone Fax

E-mail address

2. I NF O RM AT I O N ABO UT CO - I NV E S T IG AT O R #1: (as at time of application)

Last name First name Initial

Title Dr. Ms. Mr. Prof.

Institution Department

Citizenship (refer to eligibility criteria)

I NF O RM AT I O N ABO UT CO - I NV E S T IG AT O R #2: (as at time of application)

Last name First name Initial

Title Dr. Ms. Mr. Prof.

Institution Department

Citizenship (refer to eligibility criteria)

I NF O RM AT I O N ABO UT CO - I NV E S T IG AT O R #3: (as at time of application)

Last name First name Initial

Title Dr. Ms. Mr. Prof.

Institution Department

Citizenship (refer to eligibility criteria)

3. T IT L E O F R E S E AR CH PRO J E CT :

4. D E S CRI P T I O N O F R E S E AR CH PRO J E CT : Provide a summary of proposed research (500 words or less).

5. R E S E AR CH A DDRE S S : Provide the location where your research will be conducted.

Department Institution Street address (include street type, and any floor, suite or room numbers to ensure precise addressing) City Province Postal code

Telephone Fax

E-mail address

6. I NS T I T UT IO N A CCO UNT I NG A DDRE S S : Provide the name and address of the Financial Officer at the host institution responsible for the financial administration of your research award.

Name of Financial Officer Title

Institution Department

Street address

City Province Country Postal code

Telephone Fax

E-mail address Revenue Canada Registration Number

Signature ______Date

7. ETHICS A P P RO V AL

Animals Yes No Does your project involve Humans Yes No Biohazards Yes No If you answered “YES” to any of the above, please complete the relevant ethics approval form(s) at the end of this application. Please note that these approvals are a condition of award and will therefore be required prior to implementation.

8. EDUC AT I O N : Specify each degree attained, starting with most recent.

Start dates End dates Degrees Institutions Medical/Scientific fields (m/y) (m/y)

9. A C AD E M I C A WARD S AND D I ST I NCT I O NS : List all the awards received deemed relevant to this application.

Name of awards Start dates End dates Sponsors Description of awards Value/yr (m/y) (m/y)

10. ST AG E O F T R AI NI NG

Applicant name

If you are currently in training, please provide a description of your training program:

Completion date expected and specialty: Month Year Specialty

Other training you wish to share: 11. R E S E AR CH AN D / O R P RO F E S S I O NAL E X P E RI E NC E : Starting with present position, list in reverse chronological order, training and experience relevant to area of project. Please provide an explanation for any career interruptions.

12. PUBL I C AT I O NS AN D P RE S E NT AT I O NS : ( O PT IO N AL Q UE S T IO N F O R T HO S E WHO F E E L T HE Y H AV E RE L E V AN T RE F E RE NCE S T O S H AR E )

Indicate the number of publications (excluding abstracts)

Published Submitted Posters Presentations

List papers published during the past five years. Include papers accepted for publication. Abstracts should be identified as such.

13. O UT L I NE O F YO UR P RO P O S E D RE S E ARC H , YO UR O BJ E CT I V E S AND RE S E AR CH P L ANS (maximum of 2500 words or 5 pages not counting references).

14. D E S CRI P T I O N O F P RO P O S E D RE S E ARC H P RO J E CT I N L AY T E RM S ( NO N S CI E NT I F I C , G R AD E 12 RE AD AB I L I T Y ) F O R I NCL US I O N I N CHS P UBL I C AT I O NS (200 WO RDS O R L E S S ) (No attachments to this page )

15. A M OUNT R E Q UE S T E D : Summary of annual budget from April 1 to March 31. Details to be provided in Section 16.

Percentage of time principle investigator would spend on project:

one year Salaries (researcher, technicians, research assistants) Equipment Materials & supplies Other items Travel GRAND TOTAL – (Maximum $20,000)

16. F I NANCI AL R E Q UI RE M E NT F O R T OT AL P E RI O D O F PRO J E CT $ FINANCIAL BREAKDOWN

SALARIES (a) (list positions, rates of pay, key responsibilities and period of employment)

Sub-total

EQUIPMENT

(b) (list items and amounts)

Sub-total

SUPPLIES (c) (list items and amounts)

Sub-total

OTHER ITEMS (d) (list items and amounts)

Sub-total

17. ST IP E NDS , B URS ARI E S O R S UBS I DI E S : If a stipend, bursary or subsidy has been sought or received from other agencies, programs or foundations, specify source, amount(s) and period(s) of support. Please list them all.

18. C O L L ABO RAT I O N / S UP P O RT L ET T E RS : List individuals you have asked to submit a letter of collaboration/support on your behalf. (optional)

Name Position/Title Address Telephone Fax E-mail

19. M UL T I DI S CI P L I NAR Y AP P L I C AT I O N S AR E WE L COM E D . I F A M UL T I DI S CI P L I NAR Y P RO J E CT I S S O UG HT , P L E AS E I NDI CAT E HO W T HE RE S E ARC H WO UL D P RO CE E D I F O NL Y O NE P RO J E CT I S AW AR DE D .

20. SI G NAT U RE S : I certify that I have read the appropriate grant conditions on the Canadian Hemophilia Society W eb site, and I hereby agree to abide by these conditions if I am provided support Name of Principal Investigator

Signature ______Date Name of Co- Investigator #1 Signature ______Date Name of Co- Investigator #2 Signature ______Date Name of Co- Investigator #3 Signature ______Date

Head of Department

Signature ______Date President or Designated Officer Signature ______Date CANADIAN HEMOPHILIA SOCIETY / SOCIÉTÉ CANADIENNE DE L’HÉMOPHILIE

CONFORMITÉ À L’ÉTHIQUE EN MATIÈRE DE ETHICAL ACCEPTABILITY OF RESEARCH RECHERCHE SUR DES HUMAINS : INVOLVING HUMAN SUBJECTS: RAPPORT DU COMITÉ D’ÉTHIQUE POUR LA REPORT OF RESEARCH ETHICS BOARD RECHERCHE

Required for all applications proposing research involving Obligatoire pour toutes les demandes concernant des human subjects. recherches sur des humains. Funds from the Canadian Hemophilia Society may not be Les fonds que la Société canadienne de l’hémophilie a used for research involving human subjects unless the accordés ne pourront servir à des recherches sur des research proposed has been found acceptable by a humains à moins que le Comité d’éthique pour la Research Ethics Board appointed and operating in accord recherche n’ait convenu que la recherche proposée with the Canadian Institutes of Health Research, Natural répond aux normes d’éthique et/ou aux lignes directrices Sciences and Engineering Research Council of Canada, du Conseil de recherches en sciences humaines du and Social Sciences and Humanities Research Council of Canada, Conseil de recherches en sciences naturelles et Canada, Tri-Council Policy Statement: Ethical Conduct for en génie du Canada, Instituts de recherche en santé du Research Involving Humans, December 2010 (TCPS2). Canada : Énoncé de politique des trois Conseils : Éthique de la recherche avec des êtres humains, décembre 2010. Completed form must be received by the CHS as soon as (EPTC2). possible; funding of successful applications for research will be withheld by the CHS until full Research Ethics Le formulaire dûment rempli doit être reçu par la SCH dès Board approval is provided in writing to the CHS. CHS que possible; le financement pour les projets approuvés review of the applications, by its Peer Review Committee, sera retenu jusqu'à ce qu'une confirmation écrite ait été can proceed prior to Research Ethics Board (REB) reçue par la SCH confirmant que le Comité d'éthique pour approval. la recherche a complètement approuvé le projet de recherche. L'étude de la candidature par le Comité de révision de la SCH pourra débuter en l'absence de l'approbation finale du Comité d'éthique. STATEMENT FROM THE INSTITUTION* IN WHICH THE DÉCLARATION DE L’INSTITUTION* OÙ SE RESEARCH WILL BE PERFORMED DÉROULERA LA RECHERCHE

The research Ethics Board established by: Le Comité d’éthique pour la recherche établi par :

(Institution* in which the research will be performed) (Institution* où se déroulera la recherche) has examined the application for research funds a étudié la demande de financement de la recherche entitled (use the same title as on the application submitted to CHS): intitulée (utiliser le même titre que celui indiqué sur la demande présentée à la SCH) :

submitted by: soumise par :

(Name of applicant as appearing on the application submitted to CHS) (Nom du candidat tel qu’il apparaît sur la demande soumise à la SCH) and found the proposed research involving human et a convenu que la recherche proposée sur des subjects to be ethically acceptable. humains est conforme à l’éthique.

Name of institution’s representative for research involving human Nom du délégué de l’institution* en matière de recherche sur des subjects humains

Representative signature/du délégué Date

Applicant signature/du candidat Date * Par institution, on entend les universités, les hôpitaux ou les instituts * Institution includes universities, hospitals, or research institutes. de recherche CANADIAN HEMOPHILIA SOCIETY / SOCIÉTÉ CANADIENNE DE L’HÉMOPHILIE

CONFORMITÉ À L’ÉTHIQUE EN MATIÈRE DE ETHICAL ACCEPTABILITY OF ANIMAL RECHERCHE SUR DES ANIMAUX : RESEARCH: RAPPORT DU COMITÉ DE PROTECTION DES REPORT OF THE ANIMAL CARE COMMITTEE ANIMAUX

Required for all applications proposing research involving Obligatoire pour toutes les demandes concernant des animals. recherches sur des animaux. Funds from the Canadian Hemophilia Society may not be Les fonds que la Société canadienne de l’hémophilie a used for research involving animals unless the research accordés ne pourront servir à des recherches sur des proposed has been found acceptable by an Animal Care animaux à moins que le Comité de protection des Committee appointed and operating in accord with the animaux établi et dirigé conformément au Manuel sur le Guide to Care and Use of Experimental Animals of the soin et l’utilisation des animaux d’expérimentation (Vol. 1 Canadian Council on Animal Care (CCAC) (Vol. 1 [1980] [1980] rév.[1993], Vol. 2 [1984]) du Conseil canadien de rev.[1993], Vol. 2 [1984]). protection des animaux (CCPA) n’ait convenu que la recherche proposée répond aux normes établies par le Completed form must be received by the CHS as soon as CCPA. possible; funding of successful applications for research will be withheld by the CHS until full Research Ethics Le formulaire dûment rempli doit être reçu par la SCH dès Board approval is provided in writing to the CHS. CHS que possible; le financement pour les projets approuvés review of the applications, by its Peer Review Committee, sera retenu jusqu'à ce qu'une confirmation écrite ait été can proceed prior to Research Ethics Board (REB) reçue par la SCH confirmant que le Comité d'éthique pour approval. la recherche a complètement approuvé le projet de recherche. L'étude de la candidature par le Comité de révision de la SCH pourra débuter en l'absence de l'approbation finale du Comité d'éthique.

STATEMENT FROM THE INSTITUTION* IN WHICH THE DÉCLARATION DE L’INSTITUTION* OÙ SE RESEARCH WILL BE PERFORMED DÉROULERA LA RECHERCHE

The Animal Care Committee established by: Le Comité de protection des animaux établi par :

(Institution* in which the research will be performed) (Institution* où se déroulera la recherche) has examined the protocol for research funds entitled a étudié le protocole de la recherche intitulée (utiliser le (use the same title as on the application submitted to CHS): même titre que celui indiqué sur la demande présentée à la SCH) :

submitted by: soumise par :

(Name of applicant as appearing on the application submitted to CHS) (Nom du candidat tel qu’il apparaît sur la demande soumise à la SCH) and found the proposed protocol involving animals to et a convenu que la recherche proposée sur des meet the standards of the CCAC, and that the animaux répond aux normes établies par le CCPA, et facilities in which the animals will be housed and que les installations qui abriteront les animaux qui used comply with the CCAC requirements. serviront à l’expérimentation sont conformes aux exigences du CCPA.

Name of institution’s representative for research involving animals Nom du délégué de l’institution* en matière de recherche sur des animaux

Representative signature/du délégué Date

ATTESTATION DE CONFINEMENT DES RISQUES BIOHAZARDS CONTAINMENT CERTIFICATION: BIOLOGIQUES : REPORT OF THE BIOHAZARDS COMMITTEE RAPPORT DU COMITÉ D’ÉTHIQUE SUR LES BIORISQUES

Required for all applications proposing research involving Obligatoire pour toutes les demandes concernant des biohazards. recherches avec des risques biologiques. Funds from the Canadian Hemophilia Society may not be Les fonds que la Société canadienne de l’hémophilie a used for research involving recombinant DNA molecules accordés ne pourront servir à des recherches impliquant or animal viruses and cells unless the proposed research la manipulation de molécules d’ADN produites par has been found acceptable by a Biohazards Committee recombinaison ou des cellules et virus d’animaux à moins appointed and operating in accord with the Health Canada qu’un comité sur les biorisques établi et dirigé and CIHR Laboratory Biosafety Guidelines (3rd Edition – conformément aux Lignes directrices (3e édition – 2004) 2004) and the research involving biohazards will be de Santé Canada et du IRSC en matière de biosécurité carried out under the required level of containment en laboratoire n’ait convenu que la recherche proposée facilities. répond à ces normes et que la recherche comportant des risques biologiques respectera le niveau requis de Completed form must be received by the CHS as soon as confinement physique. possible; funding of successful applications for research will be withheld by the CHS until full Research Ethics Le formulaire dûment rempli doit être reçu par la SCH dès Board approval is provided in writing to the CHS. CHS que possible; le financement pour les projets approuvés review of the applications, by its Peer Review Committee, sera retenu jusqu'à ce qu'une confirmation écrite ait été can proceed prior to Research Ethics Board (REB) reçue par la SCH confirmant que le Comité d'éthique pour approval. la recherche a complètement approuvé le projet de recherche. L'étude de la candidature par le Comité de révision de la SCH pourra débuter en l'absence de l'approbation finale du Comité d'éthique. STATEMENT FROM THE INSTITUTION* IN WHICH THE DÉCLARATION DE L’INSTITUTION* OÙ SE RESEARCH WILL BE PERFORMED DÉROULERA LA RECHERCHE

The Biohazards Committee established by: Le Comité de risques biologiques établi par :

submitted by: soumise par :

(Name of applicant as appearing on the application submitted to CHS) (Nom du candidat tel qu’il apparaît sur la demande soumise à la SCH) and certifies that the proposed research will be et a convenu que la recherche proposée respectera le carried out under containment conditions meeting niveau de confinement conformément aux level in accord with the CIHR Guidelines. directives du IRSC.

Name of institution’s representative for research involving biohazards Nom du délégué de l’institution* en matière de recherche sur des humains

Representative signature/du délégué Date

Applicant signature/du candidat Date * Par institution, on entend les universités, les hôpitaux ou les instituts * Institution includes universities, hospitals, or research institutes. de recherche