Document Sample
					                                                 CALL FOR PROPOSALS 2012
                                   FOR SECOND YEAR OF A RESEARCH PROJECT ONLY

  Before completing this form, you must consult the “Instructions for preparation of applications” which can be found on the
                                                         AFM website

Family name of applicant or coordinator (1):
First name (1):

Administrative institution:

Present research position: (In the academic sector, only tenured faculty may apply)

                                          Title of the project (100 characters maximum)

                                                                Acronym (2)

                      Application number of the 1st year: _ _ _ _ _
                      Is it a Network?                                        Yes                       No

Research laboratory:
Name and address:

Phone number:                                                            Fax number:
E-mail of the applicant:

Type of Institution (for France, specify whether this is an INSERM, CNRS, AP-HP, University, Hospital, UMR
or private company. For institutions outside of France, please identify the institution precisely, i.e. University of

Family name, first name, and signature of the Laboratory Director (an original signature is required for
the signed original application, scanned signature is only authorized for e-mail submission):

(1) Capital letters
(2) Maximum of 20 alphanumeric characters; the acronym should be intelligible.
Example 1: "Development of stem cell therapies for SMA: stimulating differentiation of endogenous stem cells into motoneurons" Acronym: ENDOSTEM-
Example 2: "High throughput drug screening for Duchenne disease" Acronym: DCHEM

                                                                                      N° d'enregistrement : ............................
                                                                                      Cadre réservé à l’AFM
       I have read and approved the provisions described in the document entitled « Instructions for Call for
        Proposals » which I found on the AFM website.

       I agree to transmit a copy of my application for financing as well as a copy of the “Instructions for Call for
        Proposals” to my employer and any other research organization implicated in the realization of my project

       I recognize and accept that AFM financing is subject to respect for the procedure described in the
        “Instructions for Call for Proposals” (as a general rule, with previous signature of the letter of engagement
        by the legal representative of the parent organization—see model Letter of agreement as annex to the
        “Instructions for Call for Proposals”).

       I recognize and accept that the renewal of the funding is subordinated to an intermediate report. In case of
        no renewal submission, a final report will be sent to AFM likewise. No new submission will be reviewed
        without either.

Data collected are processed by AFM in a computer database, for management purposes. Some of the project data
(the name of the applicant, address of laboratory, the title of the project, its english lay summary (5 lines), the
duration of the project and the AFM funding amount) will be the subject of automatic data processing by the
Association Française contre les Myopathies. A public web database will include these data to provide the general
public with information regarding the progress of fundamental and clinical research related to neuromuscular
diseases. Pursuant to the French law “Informatique et Libertés” of 6 Jan. 1978, you have the right of access to and
the right to rectify the personal data retained about you. In case you wish to exercise these rights, please address
requests to the Secrétariat Permanent du Conseil Scientifique of AFM ( You have also
the right to object, on legitimate grounds, to the processing of data related to you.

                                                                     Applicant’s name :

Résumé du projet en français (1 page maximum)

Préciser :
- l’état de l’art du sujet ;
- l’intérêt général du projet dans le contexte ;
- les objectifs scientifiques ;
- la méthodologie ;
- les applications à la pathologie et à la thérapeutique humaines.
Pour tout essai clinique, joindre le synopsis du protocole.

                                                           Applicant’s name :

Abstract in English (1 page maximum)

- the state of the art on the topic of the project;
- the general interest of the project;
- the scientific objectives;
- the methodology;
- applications for human pathology and therapy.
For clinical trials, include a synopsis of the protocol.

                                                                                                       Applicant’s name :

Lay summary in English (5 lines maximum). Please do not include confidential data.

Participants in the programme
1 / If financing for one or more fellowships is requested in conjunction with this application, list the name(s) of the
candidates. Candidates must fill out applications for support themselves:

2 / Contribution of each participant

Please list in order, scientists, engineers, technicians. All the participants in the programme must sign (electronic
signatures are authorized).

 Family name, first name          Title          Institution      of time on     Role in the project
                                                                                                        (scanned’s ones
                                                                 this project
                                                                                                        are authorized)

          Team 1

          Team 2

          Team 3
          (etc …)

                                                                                                        Applicant’s name :

Budget review (in euros)
Direct project costs should be related to the realization of the project for the duration of the project. The amount
should be in euros.
If the taxes related to the costs of the projects are recoverable by the organization financed, the amounts should be
indicated without tax; if not, indicate the amounts including taxes.

List cost either with or without tax depending on tax refund regime (see instructions for Call for Proposals)

                                                                            Maximum amount granted for year 2
                                  Budget granted for the first year of     dependent on decision of the Scientific
                                             this project                  Council (amount indicated in notification
                                                                           received for the first year of the project)

Running costs




Animal experiments in the
Centre de Boisbonne


                                                                                                                   Applicant’s name :

Intermediate report and description of the continuation of the project
(in English only)
Please note that a final progress report must be provided at the latest 6 months after the end of the contract; this is valid for all
the AFM contracts, except those which were already reported on in a previous application.
Please begin the description with the page provided and continue for a maximum of 5 pages, numbering pages a, b, c...

A - Scientific progress report

a) Describe the main goal and specific aims as described in the original application

b) Progress report: Describe in detail the accomplishments including all results, challenges, setbacks and explain, if
applicable, the rationale for new directions taken

c) Quantify progress made towards the initial aims

d) Next steps

B - Clinical progress report (if any) (Please enclose copies of documents from competent authorities)

Please use as much space as needed and fill in all fields: incomplete reports will be rejected.
Do not forget to fill in the scientific and clinical progress report.

B1 - Name and address of the sponsor
     Name and address of the investigator coordinator

B2 - How many patients have already been enrolled?

B3 - Study outline:
     Expected number of patients, Kind of treatment, Expected date for First Patient In

B4 - Detailed clinical progress report by country
I. Country:
II. Center(s) where the clinical trial is being conducted?
III. Has the initial clinical trial been submitted?
     - YES
     -    NO
              IIIa. Has the initial clinical trial been submitted to a competent authority? (Name)
                          - Submission date
                          - Approval date
                          - Expected date
                          - Reasons for the lack of approval :
              IIIb. Has the initial clinical trial been submitted to an ethics committee? (Name)
                          - Submission date
                          - Approval date
                          - Expected date
                          - Reasons for the lack of approval :
IV. Has any amendment to the initial clinical trial been approved? (Name)
     - YES
     -    NO

                                                                                                    Applicant’s name :

V. Has any amendment to the initial clinical trial been approved by a competent authority? (Name)
    - Submission date
    - Approval date
    - Expected date
    - Reasons for the lack of approval :
VI. Has any amendment to the initial clinical trial been approved by an ethics committee? (Name)
    - Submission date
    - Approval date
    - Expected date
    - Reasons for the lack of approval :
VII. Description and justification of divergences according to initial objectives

C - Publications and /or Patents

- Publications acknowledging the financial contribution of AFM including papers submitted for publication,
accepted for publication or in press (References must include names of all authors, full title of the manuscript,
name of the journal the manuscript has been submitted to and date of submission).
Please send a copy of your accepted paper to

- Intellectual property and patent(s) application
(The applicant shall promptly notify AFM in writing of each Result and any patent applications filed thereon
resulting from the research Project. “Result” means any product, process, result, computer software, database, idea,
information, development, conceived or created by the applicant and his/her program team, arising out of the
research Project funded by AFM, that is or may be patentable or otherwise protectable by intellectual property

- Other comments

                                                                                  Applicant’s name :

Research field (Select the most appropriate field)
 Basic Research
   Biology of the Muscle
       Myogenesis/Muscle Development
       Muscle Regeneration and Aging
       Cytoskeleton and Matrix Proteins
       Membrane Proteins
       Signalling Pathways
       Mitochondria
       Genes/Gene Variations
       Other:      specify:__________

   Stem cells
     Origin:  Embryonic
              Foetal
              Adult

 Therapeutic Development
   Pharmacological agents
      Steroids
      HDAC
      Proteasome Inhibitors
      Anti-Oxidant Agents
      Anti-Inflammatory Agents
      Oligonucleotides
      Other:      specify:__________

   In vivo Gene Therapy
      Target gene:__________

      Mechanism:  Gene Transfer
                  Genetic Engineering (precise technique) or gene modification:__________

      Vectors:      Viral
                    Non viral
                    Other:    specify:__________

   Cell Therapy
     Origin:  Embryonic
              Foetal
              Adult

                                                                                  Applicant’s name :

   Ex-vivo Gene Therapy
     Target gene:__________

      Cell type:__________

      Mechanism:  Gene Transfer
                  Regulation of gene expression
                  Genetic Engineering (precise technique) or gene modification:__________

      Vectors:      Viral
                    Non viral
                    Other     specify:__________

 Medical Research or applications
   Patients Care
   Natural History of Diseases
   Epidemiology
   Other specify:__________

 Tool development
   Genomics/Proteomics
   Bioinformatics
   Vector
   Animal Model
   Cellular Model
   Biomarker
   High Throughput Screening
   Database
   Metabolomics


 Healthy Muscle

 Neuromuscular Disease
   Motoneuron: CMT, SMA, SLA
   Emery-Dreifuss Muscular Dystrophy
   FSHD
   Myotonic Dystrophy
   Congenital muscular dystrophies           specify:__________
   Congenital myopathies                     specify:__________
   Limb Girdle Muscular Dystrophy            specify:__________
   Metabolic Myopathies                      specify:__________
   Muscle Inflammatory Diseases              specify:__________
   Myasthenia                                specify:__________
   Mitochondrial Myopathies                  specify:__________
   Anomalies of Ionic Channels               specify:__________
   Nuclear Envelop Diseases                  specify:__________
                                                                                               - 10 -
                                                                       Applicant’s name :

   Cardiomyopathies                              specify:__________
   Distal Myopathies                             specify:__________
   Pathology of the immune system                specify:__________
   Other                                         specify:__________

 Non-Neuromuscular Disease
  Endocrine, nutritional and metabolic diseases   specify:__________
  Diseases of the nervous system                  specify:__________
  Diseases of the circulatory system              specify:__________
  Diseases of the cardiac system                  specify:__________
  Diseases of the respiratory system              specify:__________
  Diseases of the digestive system                specify:__________
  Diseases of the skin and subcutaneous tissue    specify:__________
  Diseases of connective tissue                   specify:__________


 Non Applicable

 Animal Model
  Type:     C.elegans
            Drosophila
            Zebrafish
            Yeast
            Primate
            Human
            Cat            specify:__________
            Dog            specify:__________
            Rat            specify:__________
            Mouse          specify:__________
            Others         specify:__________

 Cell Culture
  Type:      specify:__________


 Skeletal muscle
 Smooth muscle
 Heart
 Motoneuron
 Neuromuscular Junction
 Other      specify:__________

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