CLRA Research Grant Application

Please fill out and print this form

Send it to:

Children's Leukemia Research Association, Inc.                                                                                  (a.k.a. National Leukemia Research Association)

Research Grant Department

585 Stewart Avenue, Suite LL-18

Garden City, NY 11530

Please fill in all information.

USE CONTINUATION SHEETS WHERE NECESSARY!

"Thirty Six Years of Dedication to Scientific Research"

Proposed Starting Date  

Proposed Duration of Project

Research Applicant's Address
name 

last:   MI:  first:
address
city
state
zip
telephone
email

Title of Proposal

Principal Investigator

name 

last:   MI:  first:

List other departments, if any

Type of Application  

History
Is this application based on previous work? If so, source of previous support, if applicable
Has this, or a similar application been submitted elsewhere? If so, to whom
Disposition

Signature Approvals:   Director of Principal Investigator's service

  (required)   Date

Signature Approvals: Executive Director of hospital

 (required)    Date

The above signatures also certify that equipment request is justified and that similar equipment is not available for sharing within the hospital or research unit.

Human Subjects

 if yes, attach sample consent form
Date of Human Subjects Committee Clearance

Animals

 if yes, attach sample consent form
Date of Clearance

Attach Brief Abstract of Work to be Done!

Please Submit on Separate Sheets

Detailed Budget

Personnel (list all personnel involved whether or not funds are requested 

Name Title of Position  Hours/Week  Salary Fringe Benefits Total $$
Tot. Personnel $

Equipment

  $

Consultant Costs

  $

Supplies

  $

Travel, Conferences

  $

Patient Costs

  $

Alterations & Renovations

  $

Other Expenses (itemize)

  $  

                             

                             

Total Direct Costs

  $

Curriculum Vitae

Please attach C.V.'s for all professional personnel, using the following format

name

  

title

  $

department

  $
education Begin with baccalaureate training and include post-doctoral
degree
year
scientific field

honors
major research interest

role in proposed project
research support please list other research in which you are the Principal Investigator, source of support, and amount
 $
 $
 $
 $
research and/or professional experience Please Submit on Separate Sheets
Start with current position

List training

List experience relevant to area of project including appropriate published works

Note: Principal Investigator please include entire biography

USE CONTINUATION SHEETS WHERE NECESSARY
Research Plan

Please Include:

   (1) Overall objective
  (2) Background
  (3) Rationale
  (4) Specific aims

  (5) Detailed outline & discussion of specific procedures and methodology
  (6) Significance
  (7) Use of facilities - facilities available
  (8) Collaborative arrangements with other departments in hospital (e.g., Pathology, Computer Facility, etc.) or as an affiliate

Evidence to assure reviewers that corresponding Director(s) of site(s) involved agree to collaborate
USE CONTINUATION SHEETS WHERE NECESSARY
Comprehensive Progress Report  (For Renewal Application Only)

Starting Date of Project 

Period Covered by This Report

Detailed Report to Include:

  

Description of progress relative to original  research objectives

List of resulting publications, if any, including abstracts as well as related oral presentations

Short summary of results

USE CONTINUATION SHEETS WHERE NECESSARY

 


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