Lewy Body Dementia Association

Research Centers of Excellence Program

Center Application

Site Application

APPLICANT

Primary Investigator

Name, Suffix
Position/Title
Organization Name
Department
Division
Phone Number
Fax Number
Email Address

Organization

Legal name
Department
Street Address
City, State, Zip
Country
Employer Identification Number:

Authorized Organization Representative

Name
Position/Title
Organization Name
Department
Division
Phone Number
Fax Number
Email Address

Type of Application(check one)

New

Is proprietary/privileged information included in the application?

Yes

No

  1. By signing this application, the applicant certifies the statements herein are true, complete and accurate to the best of his/her knowledge. The applicant also agrees to comply with any resulting terms if he/she accepts an award. The applicant certifies he/she is aware that any false, fictitious, or fraudulent statements or claims may subject him/her to criminal, civil, or administrative penalties.
  1. The Authorized Organization Representative (AOR) is the designated representative of the recipient organization in matters related to the award and administration of its LBDA grants. The AOR should ascertain and assure that the materials the applicant organization are submitting on behalf of the applicant are the original work of the applicant and have not been used by other individuals in the preparation and submission of a similar grant application. The AOR’s signature on the grant application further certifies that the recipient organization will be accountable both for the appropriate use of funds awarded and for the performance of the grant-supported project or activities resulting from the application. This individual also is responsible to LBDA for ensuring that the organization complies with applicable Federal laws and regulations, including required certifications and assurances, its application, and the terms and conditions of individual awards.

Signature of ApplicantDate

Signature of Authorized Organization RepresentativeDate

Principal Investigator and Site Summary

In this section please include the following components: Overview of PI’s background, ongoing/current LBD professional medical education and LBD family support services provided by the PI or the institution, facilities and other resources available at the site and a summary of the clinical trial staff (e.g., study coordinators, nurse, etc.). (Maximum of 5 pages)

Appendix 1. Please fill out the following form or attach an NIH style CV. (Maximum of 2 pages)

PRIMARY INVESTIGATOR BIOGRAPHICAL SKETCH

Name
Position/Title
Education/Training
INSTITUTION AND LOCATION / DEGREE
(if applicable) / Completion Date / FIELD OF STUDY

Personal Statement

Positions and Honors

Contributions to Science

Research Support

Ongoing Research Support

Completed Research Support (last 3 years)

Appendix 2. In this section please include key clinical trial personnel, such as other PIs, study nurses, study coordinators, other allied healthcare professionals. (Please duplicate the table below for each individual as needed.)

STAFF RESOURCES(Add more tables if necessary)

Name
Position/Title,
Years in this Role
Education/Training
Areas of Interest
Name
Position/Title,
Years in this Role
Education/Training
Areas of Interest

Appendix 3

CLINICAL TRIALS EXPERIENCE

Previous clinical trial experience over the last 5 years. (Please duplicate the table below for each study and complete all information.)

Name of Study:
ClinicalTrials.gov ID (e.g. NCTXXXXXXXX)
Sponsor:
Disease entity:
Drug/device/procedure studied:
# of subjects enrolled at your site and in study:
Years you were involved (e.g. 2000-2001):
Your title/role in the study:
(Please indicate where appropriate with an X) / ___ Site Principal Investigator
___ Site Co-Investigator

Current Clinical Trials (Please duplicate the table below for each study and complete all information.)

Name of Study:
ClinicalTrials.gov ID (e.g. NCTXXXXXXXX)
Sponsor:
Disease entity:
Drug/device/procedure studied:
# of subjects enrolled at your site and in study:
Years you were involved (e.g. 2000-2001):
Your title/role in the study:
(Please indicate where appropriate with an X) / ___ Site Principal Investigator
___ Site Co-Investigator

Planned Clinical Trials (Please duplicate the table below for each study and complete all information.)

Name of Study:
ClinicalTrials.gov ID (e.g. NCTXXXXXXXX, if known)
Sponsor:
Disease entity:
Drug/device/procedure studied:
# of subjects enrolled at your site and in study:
Years you were involved (e.g. 2000-2001):
Your title/role in the study:
(Please indicate where appropriate with an X) / ___ Site Principal Investigator
___ Site Co-Investigator

Other than what is reported above, have you ever been involved with an NIH-funded clinical trial? If so, list them.

What other clinical trials are ongoing in your center for similar disorders? (Maximum of 5)

Appendix 4

CENTER DETAILS FOR LBDA’s RCOE WEBPAGE

State
City
SiteContact Person (for public inquiries, appointments, clinical trials)
Email address
Phone number

NOTE: Please provide the following files along with your application, which are needed to promote the program to the public in October, 2017.

-University logo in high resolution .jpg format

-Headshot of primary investigator

-Iconic photo of the institution

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