<p> For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Project Proposal Clinical Grant</p><p>Deadline: 01:00 pm on 12th of May 2015</p><p>CONFIDENTIAL</p><p>Read the Guidelines before completing this form</p><p>Submit the electronic format at [email protected]</p><p>Project Proposal Clinical Grant 1 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>General Information</p><p>PROJECT TITLE Project Title (MAX 150 CHARACTERS) ACRONYM Project Acronym (MAX 14 CHARACTERS)</p><p>PRINCIPAL INVESTIGATOR Name and surname of the Principal Investigator</p><p>HOST INSTITUTION Host Institution of the Principal Investigator</p><p>APPLICANT (ONE CHOICE)  SINGLE APPLICANT  CONSORTIUM</p><p>CONSORTIUM PARTNERS Partners’ name and Institution</p><p> Experimental Clinical research (ie new therapies, palliative care)</p><p>TOPICS (ONE CHOICE)  Observational Clinical research (ie biomarkers, diagnostic and prognostic </p><p>(SELECT THE PROPOSAL studies) TOPIC)  Epidemiologic studies</p><p> National Registries set up</p><p> New application</p><p>RE-APPLICATION  Revised application – previous application acronym and year: ______</p><p> Previous funded applicant – funded project acronym:______</p><p>PROJECT DURATION ______months (MAX 36 MONTHS)</p><p>AMOUNT REQUESTED (€) ______Euro</p><p>Legal Representative Principal Investigator</p><p>…………………………… ……………………………..</p><p>Signature and stamp Signature</p><p>Project Proposal Clinical Grant 2 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section I: Project Information</p><p>SCIENTIFIC ABSTRACT (max 2.500 characters)</p><p>Describe rationale, broad objectives, project design and methods, anticipated output</p><p>BACKGROUND & RATIONALE (max 3.000 characters)</p><p>Describe background and rationale of the project</p><p>GENERAL OBJECTIVES (max 2.000 characters)</p><p>Describe projects aims </p><p>METHODOLOGY (max 8.000 characters)</p><p>Describe the methodologies adopted and the study design</p><p>PRELIMINARY DATA (max 4.000 characters)</p><p>Report preliminary data collected</p><p>ADVANCEMENT BEYOND THE STATE OF THE ART (max 1.000 characters)</p><p>Describe the advancements brought by the proposal to the ALS field</p><p>RELEVANCE TO ARISLA (max 1.000 characters)</p><p>Describe how the goals of the proposal fit with AriSLA Foundation aims</p><p>Project Proposal Clinical Grant 3 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section II: Work Plan</p><p>CONSORTIUM COMPLEMENTARITIES AND SYNERGIES (max 2.500 characters) </p><p>Describe the reasons of complementarities and synergies of all participants</p><p>REFERENCES: Report references (max 20 references)</p><p>Report project references</p><p>II.1 </p><p>WORK PACKAGES: present a detailed workplan, divided into work packages (WPs), following the logical phases of the project implementation </p><p>Work Package 1: Management and Project Coordination (to be compiled only by a consortium)</p><p>WP1 DESCRIBE HOW THE MULTICENTRE PROJECT WILL BE MANAGED (max 3.500 characters)</p><p>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.</p><p>Work Package 2: Title</p><p>START DATE (MONTH) END DATE (MONTH)</p><p>WP2 DESCRIBE SPECIFIC AIMS AND STRUCTURE (max 2.500 characters)</p><p>WP2 description</p><p>WP2 TASKS (max 3.000 characters)</p><p>Describe WP2 activities to be performed T1, T2... </p><p>WP2 METHODS (max 3.000 characters)</p><p>Describe methods used to perform the WP activities Project Proposal Clinical Grant 4 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>WP2 PARTNER CONTRIBUTION (max 2.000 characters)</p><p>Specify who is doing what</p><p>Work Package 3: Title</p><p>START DATE (MONTH) END DATE (MONTH)</p><p>WP3 DESCRIBE SPECIFIC AIMS AND STRUCTURE (max 2.500 characters)</p><p>WP3 description</p><p>WP3 TASKS (max 3.000 characters)</p><p>Describe WP3 activities to be performed T1, T2... </p><p>WP3 METHODS (max 3.000 characters)</p><p>Describe methods used to perform the WP activities</p><p>WP3 PARTNER CONTRIBUTION (max 2.000 characters)</p><p>Specify who is doing what</p><p>Work Package n: Title</p><p>(Please copy, paste and fill one section FOR EACH WP)</p><p>START DATE (MONTH) END DATE (MONTH)</p><p>WPN DESCRIBE AIMS AND STRUCTURE (max 2.500 characters)</p><p>WPn description</p><p>Project Proposal Clinical Grant 5 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>WPN TASKS (max 3.000 characters)</p><p>Describe WPn activities to be performed T1, T2... </p><p>WPN METHODS (max 3.000 characters)</p><p>Describe methods used to perform the WP activities</p><p>WPN PARTNER CONTRIBUTION (max 2.000 characters)</p><p>Specify who is doing what</p><p>Project Proposal Clinical Grant 6 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>II.2 GANTT Chart</p><p>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….</p><p>II.3 List of Deliverables and months</p><p>WP n - Task n Nr of Deliverable Title Month of Delivery D1 1, 2, 6… D2</p><p>Project Proposal Clinical Grant 7 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section III: Impact on ALS (max 3.000 characters)</p><p>Describe the impact of expected results on ALS disease and evaluate which aspects of the research could have IP rights protection.</p><p>Project Proposal Clinical Grant 8 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section IV: Budget</p><p>IV.1 Overall Budget Table</p><p>REQUESTED TO ARISLA</p><p>Expressed in Euro</p><p>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</p><p>Partner 1</p><p>Partner 2</p><p>Partner 3</p><p>Partner 4</p><p>Partner 5</p><p>TOTAL requested to AriSLA</p><p>OTHER FINANCIAL SUPPORT </p><p>Specify all financial resources available in direct support of the research (max 3000 characters).</p><p>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.</p><p>Project Proposal Clinical Grant 9 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>IV.2 Cost Justification: Principal Investigator</p><p>REQUESTED TO ARISLA</p><p>Expressed in Euro</p><p>Year 1 Year 2 Year 3 TOTAL</p><p>Personnel </p><p>Materials, Supplies, Equipment</p><p>Sub-contracting (Services)</p><p>Other expenses</p><p>Overheads</p><p>TOTAL requested to AriSLA</p><p>PERSONNEL TABLE (requested to= AriSLA) </p><p>Number Total Months Average cost per month TOTAL (A) (B) (C) (D = B*C)</p><p>Post Doc </p><p>PhD student</p><p>Graduate</p><p>Other (*)</p><p>TOTAL</p><p>(*) Please specify </p><p>PERSONNEL TABLE (other personnel working on the project) </p><p>Number Total Months Granted by</p><p>Principal Investigator</p><p>Post Doc </p><p>PhD student</p><p>Graduate</p><p>Other (*)</p><p>TOTAL</p><p>(*) Please specify </p><p>Project Proposal Clinical Grant 10 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>PERSONNEL: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>MATERIALS, SUPPLIES, EQUIPMENT: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>SUB-CONTRACTING (SERVICES): Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>OTHER EXPENSES: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>Project Proposal Clinical Grant 11 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>IV.3 Cost Justification Partner n (please copy, paste number and fill one section FOR EACH PARTNER)</p><p>REQUESTED TO ARISLA</p><p>Expressed in Euro</p><p>Year 1 Year 2 Year 3 TOTAL</p><p>Personnel </p><p>Materials, Supplies, Equipment</p><p>Sub-contracting (Services)</p><p>Other expenses</p><p>Overheads</p><p>TOTAL requested to AriSLA</p><p>= PERSONNEL TABLE (requested to AriSLA) </p><p>Number Total Months Average cost per month TOTAL (A) (B) (C) (D = B*C)</p><p>Post Doc </p><p>PhD student</p><p>Graduate</p><p>Other (*)</p><p>TOTAL</p><p>(*) Please specify </p><p>PERSONNEL TABLE (other personnel working on the project) </p><p>Number Total Months Granted by</p><p>Group Leader (project partner) </p><p>Post Doc </p><p>PhD student</p><p>Graduate</p><p>Other (*)</p><p>TOTAL</p><p>Project Proposal Clinical Grant 12 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>(*) Please specify </p><p>PERSONNEL: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>MATERIALS, SUPPLIES, EQUIPMENT: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>SUB-CONTRACTING (SERVICES): Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>OTHER EXPENSES: Please describe the financial allocations foreseen in this cost category for each partner (max 1.500 characters)</p><p>Project Proposal Clinical Grant 13 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section V: Applicant</p><p> SINGLE APPLICANT  CONSORTIUM</p><p>V.1 Principal Investigator</p><p>PRINCIPAL INVESTIGATOR</p><p>Name Surname</p><p>Title Tel.</p><p>Mobile E-mail</p><p>LEGAL REPRESENTATIVE</p><p>Name Surname</p><p>Tel. Fax</p><p>E-mail Web site</p><p>HOST INSTITUTION (FILL IN COMPLETE ITALIAN NAME)</p><p>Address</p><p>Zip Code City Country</p><p>CV, RELEVANT RESEARCH EXPERIENCE AND A BRIEF DESCRIPTION OF THE HOST INSTITUTION (max 3.000 characters)</p><p>Project Proposal Clinical Grant 14 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>SELECTED PUBLICATIONS RELEVANT TO THE PROPOSAL (max 300 characters each)</p><p>Five more recent publications</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>Five more important publications</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>Five more relevant publications</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>PATENTS OWNED BY THE APPLICANT, if any </p><p>Project Proposal Clinical Grant 15 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>V.2 Partner 1 (please copy, paste, number and fill one section FOR EACH PARTNER)</p><p>CO-INVESTIGATOR 1</p><p>Name Surname</p><p>Tel. Mobile</p><p>E-mail Web site</p><p>HOST INSTITUTION (FILL IN COMPLETE ITALIAN NAME)</p><p>Address</p><p>Zip Code City Country</p><p>CV, RELEVANT RESEARCH EXPERIENCE AND A BRIEF DESCRIPTION OF THE HOST INSTITUTION (max 3.000 characters)</p><p>SELECTED PUBLICATIONS RELEVANT TO THE PROPOSAL (max 300 characters each)</p><p>Five more recent publications</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>Five more important publications</p><p>Project Proposal Clinical Grant 16 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>Five more relevant publications</p><p>1</p><p>2</p><p>3</p><p>4</p><p>5</p><p>PATENTS OWNED BY THE APPLICANT, if any </p><p>Project Proposal Clinical Grant 17 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section VI: Lay Summary </p><p>LAY SUMMARY IN ENGLISH (max 2.500 characters)</p><p>Summarize the project using lay language</p><p>LAY SUMMARY IN ITALIANO (max 2.500 caratteri)</p><p>Riassumi il progetto in un linguaggio divulgativo</p><p>Project Proposal Clinical Grant 18 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section VII: Revision Process </p><p>PROPOSED REVIEWERS (Name and contact details)</p><p>Name Surname</p><p>1</p><p>Institution E-mail</p><p>Last year of Specify the collaboration collaborating (if any) Partner</p><p>Name Surname</p><p>2</p><p>Institution E-mail</p><p>Last year of Specify the collaboration collaborating (if any) Partner</p><p>UNDESIRABLE REVIEWER (Name and contact details)</p><p>Name Surname</p><p>Institution E-mail</p><p>Justify your choice</p><p>Project Proposal Clinical Grant 19 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section VIII: Privacy Statement</p><p>INFORMATIVA ai sensi dell’art. 13 del Decreto Legislativo 30 giugno 2003, n. 196</p><p>TUTELA DELLE PERSONE E DI ALTRI SOGGETTI RISPETTO AL TRATTAMENTO DI DATI PERSONALI </p><p>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.</p><p>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. </p><p>CONSENSO</p><p>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. </p><p>Per ricevuta informazione e consenso</p><p> Autorizzo  Non Autorizzo</p><p>Data: ______</p><p>Denominazione dell’Ente </p><p>______</p><p>Rappresentante Legale Principal Investigator</p><p>………………………………………………… ………………………………………………… Timbro e Firma Firma</p><p>Project Proposal Clinical Grant 20 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>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 </p><p>Project Proposal Clinical Grant 21 For office use only:</p><p>Reference nr. FG______/2015</p><p>Acronym </p><p>Section VIII - Privacy Statement (pdf) </p><p>SAVE THE FILE WITH THE ACRONYM NAME AND SEND IT BY E-MAIL TO [email protected]</p><p>WITHIN May 12th, 2015 at 01:00 pm</p><p>Project Proposal Clinical Grant 22</p>