PERFORM Centre: Project Application Form (cover page)

Introduction

Thank you for your interest in conducting activities at the PERFORM Centre.

The PERFORM Centre integrates and accelerates the discovery, validation and sharing of the best ways of managing healthy lifestyles by supporting innovative research and knowledge exchange activities in preventive health. As a core facility of shared platforms and technical expertise, PERFORM’s resources are accessible to all who share in our mission.

For all new proposed projects, PERFORM requests some basic information on the project details, individuals involved, and resources sought. This will permit PERFORM staff to direct the applicant to the next stage.

A detailed list and descriptions of PERFORM’s available platforms, programs, and services can be found at:

Should you have any questions with regards to this application, please contact PERFORM’s Coordinator, Research Operations at:

PERFORM Centre: Project Application Form (Cover)

PERFORM Centre: Project Application Form

Application number (to be completed by PERFORM staff):
9 / 0 / 0 / 0 / 0

Please specify which of the following areas this project falls in (select only one):

Research: / Community: / Education:

If this is a request for amendment to an existing PERFORM project, please complete the following or mark N/A.

Amendment Application Date (dd/mm/yyyy)
Details of changes
(eg. personnel, funding, PERFORM resources, etc.)

Section 1: Project overview

Project Title:
Total # of participants
Application Date (dd/mm/yyyy)
Principal Investigator/Project Lead
Affiliation
University and Department; Institution, Agency, or Company
Email / Contact Phone # / Concordia ID# (if available)

Please provide an estimated timeline during which the project would take place at PERFORM

Anticipated Start Date (dd/mm/yyyy)
Anticipated End Date (dd/mm/yyyy)

Please provide a short project summary in simple language (e.g., Objectives, Rational, Procedures, Type of Participants, etc.)

Please provide a list of the individuals you expect to be involved with this project

Project Team Members, Partners, Collaborators
Last Name / First Name / Role in the project / Affiliation
(University and Department; Institution, Agency, or Company) / Email / Concordia ID#
(if available)

Section II: PERFORM Centre resources anticipated to be used

(indicate all which may apply)

Detailed descriptions of PERFORM’s platforms are available at:

PERFORM Platforms
Athletic Therapy Clinic / Cardiopulmonary Suite / Imaging Suite
Clinical Analysis Suite / Conditioning Floor / MRI
Data/Biological Specimen Storage / Sleep Lab / PET-CT
EEG/TMS / Consult Rooms / SPEC-CT
Posture and Movement Lab / MultifunctionLabs / DXA
Balance (Neurocom) / Teaching Kitchen / Ultrasound
RMSL (Isokenetics-HUMAC) / Metabolic Kitchen / Pharma Stress
Other Platforms/Equipment
Professional Services: (Details)

Section III: Funding

Indicate source(s) of funding, include funding code if available:

Section IV: Individual Agreement (For PERFORM Research members only)

PERFORM will provide support for pilot studies needing preliminary data for your future grant submissions. The following section will be assessed by PERFORM senior administration. You will be notified by email of the level of support and allocations will be done through project based individual agreements on the booking site.

Are you requesting support from PERFORM? Yes No
If yes, please complete below:
a)Please indicate exactly what you are asking for from PERFORM
(note that consumables are not covered by PERFORM)
Number of hours per platform/equipment
Number of hours per human resources
b)What are your future plans for funding?
(Include funding agencies, # participants, timeline, expected budget..etc)

Section V: Acknowledgement

Application submitted by (type name):
Application received by (PERFORM staff):

PERFORM Centre: Project Application FormPage 1