Research Proposal Form

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Research Proposal- Safety, Efficacy and Cost-Effectiveness of Supplementing Intermediate Term, Cold Storage Media with Amphotericin

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Proposal Form

In response to the reported increased incidence of postkeratoplasty fungal infection, the Eye Bank Association of America is currently accepting investigator and industry-initiated proposals focused on the safety, efficacy and cost-effectiveness of supplementing intermediate term, cold storage media with amphotericin. Please use the spaces and upload buttons below to submit your proposal.

Title of Research Proposal*

Principle Investigator Information

Name of Principle Investigator

First Last Suffix

Designation (MD, PhD, MS, CEBT, etc)

Organization/ Institution/Company*

Position/Job Title*

Phone Number*

Email Address*

Organization/Institution Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Principal Investigator CV/Resume*

Please upload your CV/Bio Sketch here.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Eye Bank or Paton Society Affiliation

Eye Bank Affiliation

Relationship with Eye Bank (Please describe)

Paton Society Member Endorsement

If you are not affiliated with an eye bank, please enter the name of the Paton Society Member who supports your project. Please include a letter of support.

Paton Society Letter of Endorsement

This is only required if the project is not associated with an eye bank or Paton Society Member.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Scientific Supervisor Information

Needed for applicants-in-training, eye-bank technicians, and nurses

Scientific Supervisor Name (if applicable)

First Last Designation

Organization/Institution

Email Address

Scientific Supervisor CV/Resume

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Co-Investigator Information

Please list the information for each co-investigator on the project.

Co-Investigator #1 Name

First Last Designation

Co-Investigator #1 Organization/Institution

Co-Investigator #2 Name

First Last Designation

Co-Investigator #2 Organization/ Institution

Co-Investigator #3 Name

First Last Designation

Co-Investigator #3 Organization/Institution

Co-Investigator #4 Name

First Last Designation

Co-Investigator #4 Organization/Institution

Grant Award Information

Total Budget Requested (Max. of $25,000)*

Organization Name*

Name of Organization to which award should be made.

Address where Grant Funds will be sent:*

Address where Grant Funds will be sent:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Research Proposal

Each proposal must include:

Background and Specific Aims of the project (Max Length: 1 page)
Significance (Max length: 1 page)
Methods / Approach (Max length: 3 pages)
Qualifications & Facilities (Max Length: 1 page)
References (Max length: 2 pages)

Background & Aims

Include the information in the space below or upload the information using the tool below. (Max Length: 1 page)

Background & Aims*

State the background of the project and the specific aim(s) of this study.

Background & Aims File Upload

Please upload the document related to the background and aims of the research proposal here.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Significance

Use this section to state the significance of this project to eye banking and/or corneal transplantation.

Significance*

Explain the significance of this project to eye banking and/or corneal transplantation.

Significance File Upload

Upload your documents detailing the significance of this project.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Methods & Approach

Include the information in the space below or upload the information using the tool below. (Max Limit: 3 pages)

Research Plan*

Provide a concise description of the methodology and approach that will be used. Relate the research techniques directly to the specific aim(s). (Limit: 3 pages)

File Upload

Upload a document that outlines the research plan including the methods and approach.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Qualifications & Environment

Include the information in the space below or upload the information using the tool below. (Max Limit: 1 page)

Qualifications to Carry Out Study*

What are your qualifications to carry out this study? (Word limit: 500 words)

Environment*

How is the environment at your organization/institution/company conducive to carrying out the proposed study? Include the facilities, personnel, resources, and infrastructure that are available to you and how they will help with the conduction of this study. List responsibilities of key personnel pertaining to this study. (Word limit: 500 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)*

Qualifications & Environment File Upload

Use this tool to upload a document detailing your qualifications and the facilities and resources available to you to the carry this study.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Budget

Provide a detailed itemized budget for the proposed project. List the budget in the space below or upload using the tool below. (Max Length: 1 page)

Budget*

Itemize all proposed expenditures. Provide a brief justification for any item for which the need may not be obvious. (Max Length: 1 page)

Budget File Upload

Upload your itemized budget here.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

References

Include all projects and papers that are being referenced in producing this research. (Max Limit: 2 pages)

References

Upload list of references here.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Supporting Documents

Include any additional documents (including tables and figures) that support your proposal.

Supporting Documents File Upload

Include any additional documents, tables, etc, here.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Research Safeguards

Animal 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 Subjects

Safeguarding 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 Approval

If applicable, please upload copies of the consent form and IRB approval statement.

Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, Max. file size: 25 MB.

Acknowledgement of Terms

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.

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Research Proposal- Safety, Efficacy and Cost-Effectiveness of Supplementing Intermediate Term, Cold Storage Media with Amphotericin

Proposal Form

Principle Investigator Information

Eye Bank or Paton Society Affiliation

Scientific Supervisor Information

Co-Investigator Information

Grant Award Information

Research Proposal

Background & Aims

Significance

Methods & Approach

Qualifications & Environment

Budget

References

Supporting Documents

Research Safeguards

Acknowledgement of Terms

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