Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

Young Investigator Grant Application by 1jEr4T7

VIEWS: 4 PAGES: 17

									Young Investigator Application                                                 Principal Investigator______________________


              AMERICAN FOUNDATION FOR SUICIDE PREVENTION
                   120 Wall Street, 29th Floor  New York, NY  10005 (212) 363-3500 Ext. 2015


                              Young Investigator Grant Application
          THIS COMPLETED APPLICATION IS TO BE SUBMITTED ELECTRONICALLY ALONG WITH ANY
                                    SUPPLEMENTAL MATERIAL.

Application Date:            _____________                  Amount Requested: $___________ (Total amount requested)

Grant Term:        From: ____/____/____                     Select one choice below that applies
                   To:   ____/____/____                      New Application
                                                             Revised App: Current ID #: ______________________
                                                             Suicide Supplement: Granting Inst:________________
                                                                Title:________________________________________
Please read the Foundation's Policies for Young Investigator Grants before completing this application.

Project Title (limit to 100 characters):



Key Words (3 to 5 key words on target population, special methods, etc.):



Principal Investigator (last, first)                Degree(s)                               Signature


Institution

___________________________________________________________________________________________________________
Department


Address--line 1                                                       Phone number


Address--line 2                                                       Fax number


City, State, Zip code                                                 E-mail Address
_________________________________________________                     __________________________________________________

__________________________________________________                    __________________________________________________
Department head                                                       Signature


                                                       For Internal Use Only

                                       Administrative Application #: ____________________



                                                                A-1                                      Revised: 08/01/2011
Young Investigator Application                                              Principal Investigator______________________




Mentor for Principal Investigator (Last, First)   Degree(s)                              Signature


Institution

_________________________________________________                   __________________________________________________
Address—line 1                                                      Phone Number

_________________________________________________                   __________________________________________________
Address—line 2                                                      Fax Number

_________________________________________________                   __________________________________________________
City, State, Zip Code                                               E-mail Address




                                                              A-2                                     Revised: 08/01/2011
Young Investigator Application                                         Principal Investigator______________________



                                 PRINCIPAL INVESTIGATOR ASSURANCE FORM

Please read and sign the following assurance form. All questions regarding grant policies, including
questions about eligibility, should be directed to grantsmanager@afsp.org prior to submitting the
application.


I hereby certify that the information in this application is true and correct to the best of my knowledge. If a
Young Investigator Grant award is made, I understand that it is subject to the terms, conditions, and procedures
stated in the AFSP Policies for Young Investigator Grants. I have reviewed this document and agree to abide by
all stated policies. I understand that failure to comply with these policies may result in termination of the grant.
If a grant award is made, I agree to accept responsibility for the scientific and ethical conduct of the research. I
understand that if the grant is not started within 6 months of award date, it will be cancelled.



___________________________________                   _____________________________
Signature of Principal Investigator                   Date


___________________________________                   _____________________________
Signature of Mentor                                   Date




                                                        B-1                                       Revised: 08/01/2011
Young Investigator Application                                          Principal Investigator______________________

                                          APPLICATION CHECKLIST

Please use the forms in this package for your submission. Check boxes are provided next to each application
section for your convenience. All items in this application are required. If you are completing this form
electronically, you may [ctrl]+click on the section headings in this list to be taken to the respective sections.



                                                                                     SECTION
     Cover Page                                                                         A

     Assurance Form                                                                     B

     Application Checklist                                                              C

     Abstract of Proposed Research (1 page)                                             D

     Budget (1 page)                                                                    E

     Budget Justification (2 pages)                                                     F

     Biographical Information (2 pages per person)                                      G

     Project Description (5 pages)                                                      H

     Project Timeline (1 page)                                                          I

     Recommendation of Mentor (no limit)                                                J

     Certification for Protection of Human and Animal Subjects (2 pages)                K

     References (no limit)                                                              L

     Appendices (no limit)                                                              M




                                                        C-1                                       Revised: 08/01/2011
Young Investigator Application                                                Principal Investigator______________________


                                       ABSTRACT OF PROPOSED RESEARCH
                                                       Limit one page.
Principal Investigator:

Name of Mentor:

Project Title:

AFSP has identified underfunded areas of research. Check the areas (if any) that describe the focus of your application.
Psychiatric Disorders:          Schizophrenia          Substance use disorders                Personality disorders
                                MDD                    Bipolar Disorder                       Anxiety disorders
Interventions:                  Pharmacological        Psychological
Racial or Ethnic Minorities:  Native American          African American  Hispanic  Asian
Gender or Age Groups:           Middle Aged Men  Older Adults
Special Populations:            LGBT                   Survivors
Point-of-Service:               Hospitals              Prisons                Military       Primary Care
Include in abstract: research aims and hypotheses, sample, measures, procedures, potential impact, and next steps in this
line of the proposed research. Complete using language that can be understood by an informed lay audience. Do not use
abbreviations or technical terms without providing a clear definition or explanation.




List all grant personnel in the table below. Include all current and/or recent institution(s) and project role(s).
            Key Personnel                              Institution                                Role on Project




                                                             D-1                                           Revised: 08/01/2011
Young Investigator Application                                                 Principal Investigator______________________


                                                          BUDGET
                                                      Limit one page

Budget must not exceed $42,500 per year, or $85,000 for a two-year period. This includes the mentor fee of $5,000 per
year. Please consult the Policies for Young Investigator Grants for information on allowable and non-allowable costs.


PERSONNEL*                                                                       Dollar Amount Requested
                                             % Time on     First Year Salary   First Year Fringe First Year Sal.   Second Year
         Name             Role on Project    Project **         Request             Benefits        + Fringe       Sal. + Fringe
                             Principal
                           Investigator




                                            SUBTOTALS

CONSULTANT COSTS
                                                                                                    First Year     Second Year
                                                                                                      Totals          Totals



                                                                                SUBTOTALS


OTHER THAN PERSONNEL
                                                                                                    First Year     Second Year
                                                                                                      Totals          Totals




                                                                                SUBTOTALS



                                                                               GRAND TOTAL


 * List all key personnel and their percent time, regardless of whether salary support is requested. All personnel
   who will be playing a substantial role on the project must be specifically named and biographical information included
   in Section G.

** The Principal Investigator must devote a minimum of 10% time to the proposed project.




                                                            E-1                                            Revised: 08/01/2011
Young Investigator Application                                           Principal Investigator______________________

                                        BUDGET JUSTIFICATION PAGE
                                                   Limit two pages

PERSONNEL. Briefly describe duties and responsibilities of all key personnel.




CONSULTANT COSTS. Briefly describe the tasks to be performed by all consultants.




OTHER THAN PERSONNEL. Please explain all other budgeted items.




                                                         F-1                                       Revised: 08/01/2011
Young Investigator Application                                               Principal Investigator______________________


                                          BIOGRAPHICAL INFORMATION
                                               Limit two pages per person

Provide the following information for all personnel who will play a substantial role on the project including the mentor. Do not
exceed 2 pages per person and do not append full CV.

Name                                                Degree                           Sex: Male            Female

1.   EDUCATION (Begin with baccalaureate degree and include postdoctoral training, if applicable.)

        Institution and Location                 Degree            Year Conferred                  Scientific Field




2. EXPERIENCE. List in chronological order professional positions held, concluding with present position.




3. SELECTED PEER-REVIEWED PUBLICATIONS. List (in chronological order) representative publications
   relevant to this application.




                                                             G-1                                         Revised: 08/01/2011
Young Investigator Application                                              Principal Investigator______________________


4. RESEARCH SUPPORT. List funded research projects relevant to this application (Federal and non-federal support).



Past Support:

        Dates            Source          Amount            Title                  Your Role on Project




Current Support:

        Dates            Source          Amount            Title                  Your Role on Project




Pending Support: Please list all pending applications and briefly describe below any overlap in the research proposed in
any of these applications with that proposed in the present application to AFSP.

        Dates            Source          Amount            Title                  Your Role on Project




        Overlap of Proposed Research




                                                           G-2                                           Revised: 08/01/2011
Young Investigator Application                                      Principal Investigator______________________


                                          PROJECT DESCRIPTION
                                               Limit five pages

SECTION I. SPECIFIC AIMS/HYPOTHESES (one-half page maximum)




SECTION II. BACKGROUND AND SIGNIFICANCE (one page maximum)




SECTION III. RESEARCH METHODS. Detail the methods that will be used to collect and analyze all data. Please
include the number of subjects and power analysis. (three and one-half pages maximum)




                                                      H-1                                     Revised: 08/01/2011
Young Investigator Application                                            Principal Investigator______________________


                                             PROJECT TIMELINE
                                                  Limit one page

                                 Please provide a timeline for key project activities.




                                                         I-1                                        Revised: 08/01/2011
Young Investigator Application                                    Principal Investigator______________________


                    RECOMMENDATION OF YOUNG INVESTIGATOR GRANT MENTOR
                                   To be completed and signed by Mentor
                                               No page limit

Applicant Name: _______________________________________________________________________

Mentor Name: _________________________________________________________________________


    1. PLEASE INDICATE THAT YOU HAVE READ AND UNDERSTAND THE YOUNG INVESTIGATOR GRANT POLICIES.
       YES _______ NO _______

    2. PLEASE DESCRIBE THE RELATIONSHIP OF THE APPLICANT’S PROPOSED RESEARCH PROJECT TO YOUR OWN
       WORK.




    3. PLEASE DESCRIBE YOUR RELATIONSHIP WITH THE APPLICANT TO DATE, AND YOUR ROLE IN MENTORING
        THE APPLICANT IN THE PROPOSED RESEARCH PROJECT AND OTHER ACTIVITIES LISTED IN THE APPLICANT’S
        TRAINING PLAN. INDICATE THE FREQUENCY AND NATURE OF THE ANTICIPATED CONTACTS WITH THE
        APPLICANT DURING THE RESEARCH FELLOWSHIP PERIOD (I.E. IN-PERSON, E-MAIL, TELEPHONE,
        TELECONFERENCE, VIRTUAL REALITY, ETC.). INCLUDE ALL THAT APPLY.




    4. PLEASE INDICATE HOW THE IRB APPROVAL, START DATE, AND PROGRESS REPORTS WILL BE REVIEWED
       WITH THE MENTOR.




    5. PLEASE INDICATE THAT THE FINANCIAL FINAL REPORT FROM THE FINANCIAL OFFICER WILL BE REVIEWED
       AND SUPERVISED REGULARLY AND THE FINAL REPORT WILL BE REVIEWED.




                                                   J-1                                      Revised: 08/01/2011
Young Investigator Application                               Principal Investigator______________________


    6. PLEASE EVALUATE THE APPLICANT’S QUALIFICATIONS TO CARRY OUT THE PROPOSED RESEARCH PROJECT
       AND HOW IT FITS INTO THE POSTDOCTORAL CANDIDATE’S TRAINING AND PREPARATION FOR AN
       INDEPENDENT RESEARCH CAREER.




    PLEASE LIST THE PI, TITLE, AND DATES OF ALL AFSP YOUNG INVESTIGATOR OR POSTDOCTORAL RESEARCH
    FELLOWSHIP GRANTS ON WHICH YOU HAVE BEEN OR CURRENTLY ARE A MENTOR. PLEASE NOTE THAT ONE
    CANNOT SERVE AS A MENTOR FOR MORE THAN TWO AFSP GRANTEES AT A TIME. WHETHER YOUNG
    INVESTIGATORS OR POSTDOCTORAL RESEARCH FELLOWS.

     PRINCIPAL INVESTIGATOR       PROJECT TITLE                        DATES OF PROJECT




MENTOR’S NAME

SIGNATURE




                                                  J-2                                  Revised: 08/01/2011
Young Investigator Application                                          Principal Investigator______________________


                 CERTIFICATION FOR PROTECTION OF HUMAN AND ANIMAL SUBJECTS
                                                 Limit two pages

        Principal Investigator:

        Project Title:
                                 RESEARCH INVOLVING HUMAN AND ANIMAL SUBJECTS

        Safeguarding the rights and welfare of human and animal subjects involved in activities
        supported by grants from the American Foundation for Suicide Prevention is the responsibility of
        the institution that receives the funds awarded. The proposed research must be submitted to the
        sponsoring institution’s Institutional Review Board (IRB) at the time the application is submitted
        to AFSP. If an award is made by AFSP, no funds will be released until proof of IRB approval is
        received and subsequent payments require that IRB approval remain current.

        Investigators should describe on the following page assurances regarding the risks to human and
        animal subjects and the adequacy of protection against possible risk. Include available
        information regarding their data and safety monitoring plan as it relates to human participants
        and animals. Please include risks, adequacy of protection against risks, safety monitoring,
        potential benefits of proposed research, and the importance of knowledge gained.

        Check one of the following statements:

                This application does not propose any activities that would involve human beings or
                 animals as research subjects.

             This application proposes activities involving human and animal subjects and…

                was reviewed by our institution’s IRB in accordance with current NIH policy and
                 approved on ___/___/_____ (date). A copy of IRB approval is attached.

                was submitted to our institution’s IRB on ___/___/_____ (date). I understand that proof
                 of IRB approval must be submitted to AFSP within six (6) months of start date if award is
                 made.




        ____________________________________________________________________________________
        Signature of Institutional Office authorized to sign proposals             Date



         Title                                                     Telephone (area code, number, extension)

                                                       K-1                                        Revised: 08/01/2011
Young Investigator Application                                      Principal Investigator______________________




                Consideration Regarding Human and Animal Subjects (Continued)
Describe assurances regarding the risks to human and animal subjects and the adequacy of protection against
possible risk.




                                                     K-2                                      Revised: 08/01/2011
Young Investigator Application                   Principal Investigator______________________


                                 REFERENCES
                                 No page limit




                                     L-1                                   Revised: 08/01/2011
Young Investigator Application                                              Principal Investigator______________________

                                                     APPENDICES
                                                      No page limit

Appendices should be limited to copies of unpublished instruments, manuals or other materials directly related to the
proposed research. Do not include copies of previous publications.




                                                           M-1                                          Revised: 08/01/2011

								
To top