Expression of interest form FINAL 4May12 by kRD76wzt


									Asthma UK Centre for Applied Research
Expression of interest form                                                                      REF
 Compliance with the Data Protection Action 1998
 In accordance with the Data Protection Act 1998, the personal data provided on this form will be processed by Asthma UK, and
 may be held on computerised databases and/or manual files.

 Asthma UK’s vision is ‘control over asthma today, freedom from asthma tomorrow’
 Before preparing your expression of interest, you should refer to the call for applications and Asthma
 UK’s Research Strategy 2011-16 at
 research/for-researchers/ to ensure you are able to meet the requirements for funding for the Asthma
 UK Centre for Applied Research.

Please read this form along with the call for applications and draft general Terms and Conditions carefully before
attempting to answer any questions. All parts of the form must be completed and supporting information and
evidence must be supplied where appropriate or requested. Failure to provide the requested information, make a
satisfactory response to any question, or supply documentation referred to in responses within the specified
timescale may mean that you will not be invited to participate further.

This form should be completed in typescript of 11 point Trebuchet/Arial font with 1.5 line spacing. It is the
responsibility of the applicants to ensure that word count limits are met for each section of the form. Applications
that do not conform to the specified format may not be accepted.

Once completed, please email this form as an attachment to and send an original signed
copy to: Research Team, Asthma UK, Summit House, 70 Wilson Street, London EC2A 2DB
Both electronic and signed paper copies must be received by Asthma UK by the closing date of:

Friday 15 June 2012, 5pm
 Section 1: Name of applicant(s) (please add more boxes for additional co-applicants if required)
 Lead applicant

 Co-applicant (1)

 Co-applicant (2)

 Co-applicant (3)

 Section 2: Present employment of lead applicant                          Section 3: Address for correspondence
 Work title






 Section 4: Start date
 Proposed starting date (month/year)

                                                                                                                    Page 1 of 8
Research activities

 Section 5: Vision, strategy and execution (500 words maximum)

 Outline your overall strategy for the Centre, demonstrating alignment with Asthma UK’s vision as well as the
 development and integration of existing programmes, expertise and collaborations. Include details of the
 project management structures that will be in place to coordinate the delivery of the proposal.

Enter text here

 Section 6: Proposed research programme (1200 words maximum)

 Describe the programme of research for the Centre, providing examples of research questions to be covered
 and how they align with Asthma UK’s research priorities as indicated for the Centre.

 This section should describe how the applicants will establish a multi-centre, multidisciplinary partnership that will
 deliver a mixed-method programme of applied research and improve asthma outcomes within 5 to 10 years. Please
 refer to the selection criteria in the call for applications for further guidance.

Enter text here

Section 7: Facilities and environment (300 words maximum)

Please describe the infrastructure and resources available to support the proposed Centre and outline its
suitability to underpin the establishment of an effective platform for delivering the overall strategy for the

Enter text here

                                                                                                            Page 2 of 8
Potential impact on people affected by asthma

 Section 8: Relevance to asthma (300 words maximum)

 Will the research undertaken through your proposal be
 exclusively about asthma?                                   Yes/No (delete as appropriate)
 If no, please give details

 Also, please indicate how the proposal has been informed by the real-life needs and experiences of people
 affected by asthma.

Enter text here

 Section 9: Research outcomes (300 words maximum)

 Please outline the clinical importance of the proposed research areas in terms of impact on the lives of people
 with asthma, specifically on reducing asthma exacerbations, maximising treatment options and/or encouraging
 good asthma control. Indicate the likely timescale for the outcomes of your research and give brief reasons for
 the suggested timescale.

 1-2 years                    3-5 years              5-10 years                 More than 10 years

Enter text here

 Section 10: Patient and public engagement (200 words maximum)

 Please outline plans for patient and public engagement in relation to your proposal for the Asthma UK Centre
 for Applied Research.

Enter text here

 Section 11: Commercialisation and implementation of research (200 words maximum)
 Outline the arrangements and experience the partnership would have to take forward the commercial
 exploitation and clinical implementation of research arising from the Centre. This should also include an
 explanation of how you would work with Asthma UK to do so, in order to achieve maximum benefits for people
 affected by asthma.

Enter text here

                                                                                                      Page 3 of 8
Capacity- and capability-building

 Section 12: Partnership working (300 words maximum)

 Provide a brief description of the key research partnerships/collaborations that will underpin the delivery of
 your Centre proposal and an explanation of why they are beneficial.

Enter text here

 Section 13: Training (200 words maximum)
 Outline the training plan to be implemented at the proposed Centre to reflect national and international
 leadership in the field.

Enter text here

 Section 14: Institutional support (200 words maximum)

 Outline the institutional resource commitment, reflecting a strong commitment for long-term support of the
 Centre and sustainability at the end of the core funding period.

Enter text here

                                                                                                       Page 4 of 8
Networking and influence

 Section 15: Existing affiliations and associations (300 words maximum)

 Provide details of the existing connections of the partnership to the healthcare community, policy and
 decision makers, other funding bodies, research infrastructure and NHS R&D infrastructure in the field of
 applied asthma research and associated areas.

Enter text here

                                                                                                     Page 5 of 8
Track record

 Section 16: Expertise and knowledge production (300 words maximum)

 Provide details of the expertise of the partnership in applied asthma research. Describe the contributions the
 applicants have made to improve understanding in the field. Reference key publications in the standard
 scientific format (ie Harvard or Vancouver style).

Enter text here

 Section 17: Curriculum vitae (1 page per person)

One curriculum vitae should be completed for each applicant (both lead and co-applicants). Provide details of:
       Work contact information
       Academic/professional qualifications
       Employment - present and previous position(s) held
       Key publications in the standard scientific format (ie Harvard or Vancouver style) - list details of
        references that you feel will aid your application. Include full title and all authors (failure to cite a
        reference in full may impede processing of your application). References for up to 10 of the most recent
        and/or relevant papers for each applicant will be adequate.
       Current research grants held - please list all current Asthma UK and non-Asthma UK grants held, providing
        details of the grant reference number (if available), title, awarding body, value and funding period.
       Any other information you feel will demonstrate your track record in, and commitment to, applied
        asthma research.

Enter text here

                                                                                                        Page 6 of 8
   Justification of requested resources

Section 18: Estimated financial support requested

Please calculate according to Asthma UK’s financial years, with a realistic start date of no earlier than 1 October 2013

                              Oct 2013 -    Oct 2014 -      Oct 2015 -      Oct 2016 -      Oct 2017 -
                              Sept 2014     Sept 2015       Sept 2016       Sept 2017       Sept 2018
Estimated total gross

Sub total (salaries)


List here

Grand total

Section 19: Use of funding (300 words maximum)
Outline how Asthma UK funding would be allocated to facilitate the establishment and development of the

   Enter text here

                                                                                                                Page 7 of 8
Section 20: Finance department
Named contact





Section 21: Signatures
Declaration from lead applicant:
         I have read Asthma UK’s draft general Terms and Conditions and agree to abide by them. I will also agree,
          in principle, to future iterations of these Terms and Conditions at the point at which I submit a full
          application, should this expression of interest be successful.
         I note that no alterations can be made to the award without prior approval from Asthma UK.
         I shall be actively engaged in day to day control of the project.
         I understand that progress reports will be required by Asthma UK.
         I declare that the information given on this form is complete and correct.

Lead applicant                                Signature                                          Date

Co-applicants                                 Signature                                          Date

Declaration from Finance Officer
I confirm that I have read and accept the conditions under which grants are awarded and that the estimated salary
details given include a provision for nationally agreed pay awards. I have checked the financial details of this
research application and agree to administer the award if made.

Finance Officer                               Signature                                          Date

Section 22: Monitoring information

Please state where you heard about the Asthma UK Centre for Applied Research and the 2012 call for expressions of

                                                                                                         Page 8 of 8

To top