"*" indicates required fields Pilot Research Grant ApplicationTitle of Research Proposal* Principal Investigator InformationName of Principal Investigator First Last Suffix Organization/Institution* Position/Job Title* Phone*Email* Organization Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Principal Investigator CV/Resume*Please upload your CV/Bio Sketch here. Drop files here or Select files Accepted file types: pdf, gif, jpg, doc, docx, Max. file size: 25 MB. Eye Bank/ Paton Society AffiliationIf you are not a staff member of an eye bank or a current Paton Society Member, please include any affiliations you may have to an EBAA member eye bank or Paton Society Member.Eye Bank Affiliation Relationship with Eye Bank (Please describe) Paton Society Member EndorsementIf you have the endorsement of a Paton Society Member, please include the member’s name and upload a letter of support. Paton Society Letter of EndorsementThis is only required if the project is not associated with an eye bank or Paton Society Member. Drop files here or Select files Accepted file types: pdf, jpg, gif, doc, docx, Max. file size: 25 MB. Scientific Supervisor InformationNeeded for applicants-in-training, eye-bank technicians, and nursesScientific Supervisor Name (if applicable) First Last Suffix Organization/Institution Email Address Scientific Supervisor CV/Resume Drop files here or Select files Accepted file types: pdf, gif, jpg, doc, docx, Max. file size: 25 MB. Co-Investigator InformationPlease list the information for each co-investigator on the project.Co-Investigator #1 Name First Last Suffix Co-Investigator #1 Organization/Institution Co-Investigator #1 Email Co-Investigator #2 Name First Last Suffix Co-Investigator #2 Organization/Institution Co-Investigator #2 Email Address Co-Investigator #3 Name First Last Designation Co-Investigator #3 Organization/Institution Co-Investigation #3 Email Address Co-Investigator #4 Name First Last Designation Co-Investigator #4 Organization/Institution Co-Investigator #4 Email Address Grant Award InformationTotal Budget Requested (Max. of $7,500)* Organization Name*Name of Organization to which award should be made. Address where Grant Funds will be sent:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Organization W-2Please provide the W-2 for the organization that will receive the funds if the proposal is accepted. Accepted file types: pdf, png, jpg, , Max. file size: 256 MB.Research ProposalPlease complete all items below and use the file upload tools if necessary to upload portions of the proposal, IRB approval, additional materials, etc.Purpose of Study:*State the specific aim(s) of this study. (Word limit: 200 words)Background:*Summarize previous studies related to this project. (Word limit: 500 words)Significance:*Why is this study significant to eye banking and/or corneal transplantation? (Word limit: 200 words)Research Plan:*Provide a concise description of the methodology to be used. Relate the research techniques directly to the specific aim(s). (Word limit: 400 words)Qualifications:*What are your qualifications to carry out this study? (Word limit: 200 words)Environment:*What facilities do you have to carry out this study? List responsibilities of key personnel pertaining to this study. (Word limit: 200 words)Please list any other funds/resources that you have received to assist in the completion of this study (e.g., technician support, equipment, etc.)? List all grant applications pertinent to this study that are currently submitted or planned within the next year. (Word limit: 150 words)Additional Documents & FiguresUse the tool below to upload any additional documents and figures in support of the proposed research.Additional Documents & FiguresUpload any additional documents that are important to your proposal. Drop files here or Select files Accepted file types: pdf, jpg, doc, docx, , Max. file size: 25 MB. BudgetUse the field below to submit your budget, or use the upload tool to submit a document containing the itemized budget.Budget:*Itemize all proposed expenditures. Provide a brief justification for any item for which the need may not be obvious. (Word limit: 150 words)Budget:Upload itemized list of all proposed expenditures. Provide a brief justification for any item for which the need may not be obvious. (Word limit: 150 words) Drop files here or Select files Accepted file types: pdf, jpg, doc, docx, Max. file size: 25 MB. Research SafeguardsAnimal Subjects (if applicable)It is the policy of the Eye Bank Association of America that institutions and organizations using experimental animals in projects or demonstrations supported with funds from EBAA grants shall assure the EBAA in writing of compliance with the Principles for Use of Laboratory Animals as stated in the regulations of the Department of Health & Human Services. I certify that (the Institution named in this application) is in compliance with the principles for use of laboratory animals under the regulations of the Department of Health & Human Services. I certify that the research submitted for consideration by the Eye Bank Association of America has been reviewed by the appropriate institutional committee and approved with respect to compliance with the principles for the care, use and treatment of experimental animals under the regulations of the Department of Health & Human Services. Human SubjectsSafeguarding the rights and welfare of human subjects involved in research supported by the Eye Bank Association of America is the responsibility of the institution to which the support is awarded. It is the policy of the Eye Bank Association that no grant to support research involving human subjects be made unless the research is given initial and continuing review and approval by an appropriate committee of the applicant’s institution. This review should assure that (a) the rights and welfare of the individuals involved are adequately protected, (b) the methods used to obtain informed consent are adequate and appropriate, and (c) the risks to the individual are outweighed by the potential benefit of him or her by the importance of the knowledge to be gained. I certify that the institution that is named in this application is in compliance with the U.S. Department of Health and Human Services, Public Health Service requirements regarding the initial and continuing review of research involving human subjects. I certify that the research project named in this application which is being submitted for consideration by the Eye Bank Association of America has been reviewed by the appropriate institutional committee and approved with respect to the study of human subjects as adequately protecting the rights and welfare of the individuals involved, employing adequate methods of securing informed consent from these individuals, and not involving undue risk in the light of the potential medical benefits to be derived therefrom. Consent Forms & IRB ApprovalIf applicable, please upload copies of the consent form and IRB approval statement. Drop files here or Select files Accepted file types: pdf, doc, docx, gif, jpg, Max. file size: 25 MB. Acknowledgement of Terms. If the project is approved for support, I agree to the following: (Please check each box)* I will provide a 6-month report and a project report and financial statement at the completion of the one-year award duration. Upon completion of the one-year award duration, I will return any unexpended funds to the Eye Bank Association of America. I will acknowledge support of the Eye Bank Association of America in all publications resulting from this grant. I will submit my results for presentation at a future EBAA meeting within two years of finishing the research. I have not applied nor have been awarded governmental or philanthropic funding to carry out this project. Please check this box if all of the information in this application is correct and complete.* All information is correct and the application is complete.
