Application Form

* First Name

Initial

Last

Institution

Title

Street Address

Address continued

City

Province Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal Code

Email Address *

Title of Proposed Study *

Principal Investigator(s):

Co-Investigator(s) and Institution:

Lay Description: Please provide a 100-200 word lay summary of the project.

Study Abstract: Please provide a 250-300 word structured abstract. Include the following headings *OBJECTIVE *METHODS *RESULTS *CONCLUSIONS

Approximate Total Budget

Financial support requested from B-CHERP:

Provide an itemized budget for how the operating grant will be used:

Name of Financial Officer * First Name

Initial

Last

Title

Institution

Department

Street Address

Address continued

City

Province Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Postal Code

Email Address *

Revenue Canada Registration Number

Please provide a study proposal (10 page maximum; letter size, font 12, single spacing, 2cm margins, excluding references). See #3 below.

Please provide a copy of your ERB approval (if available) for this study. Approval must be obtained before funding is dispersed.

Please provide a current copy of your CV/Resume including a listing of publications

Please include signed copies of the applicable forms (Biohazards, Animal Care, REB).

Note:

1. If electronic copies are not available for any of these forms, they can be faxed to 416-864-5251

2. A signature page must be completed and mailed in to head office. This is available for download at https://www.ahcdc.ca/storage/files/bcherp-ethic-forms.doc

3. Please attach an electronic copy of your complete research proposal, a 10 page maximum (letter-size, font 12, single spacing, 2cm margins, excluding references). Proposal to contain:
a. What you want to do (central hypothesis, research question, specific objectives)
b. Why this is a reasonable thing to do (review of previous work done on the subject matter, rationale)
c. Why this is important (new knowledge to be obtained, improvements to health which will result)
d. How you are going to do it (work plan, timelines, analysis and interpretation of results, pitfalls, ways around the pitfalls, alternatives)
e. Why you should do it (relevant prior experience and skills, collaborators for technical gaps, preliminary data showing feasibility)

* First Name

Initial

Last

I have read and agree to comply with the conditions governing the B-CHERP grant program.

I certify that the statements herein are true, complete, and accurate to the best of my knowledge.

I consent to the sharing of personal and scientific information from this submission with the members of the B-CHERP peer-review panel

As Grantee, I and my co-investigators shall indemnify AHCDC and BAXALTA, NOW PART OF SHIRE, and their directors, officers and employees for any and all damages, costs, expenses and other liabilities, including reasonable attorney's fees, incurred in connection with any third-party claim, action or proceeding arising or resulting from Grantee's receipt and use of the grant, and any act or omission, negligence or misconduct of Grantee or any of its employees, agents or representatives involved in any research resulting therefrom.