Period Covered by Proposal:January to December 2016

Period covered by Proposal:January to December 2016

General Information

Please refer to the SRC Program Manuals for all budget information linked to your SRC relationship.

The SRC Program is bound by a limited budget which cannot be exceeded. This budget is divided over all center links who receive a different financial allocation depending on their level within the program:

A level links receive an annual allocation of maximum 15,000 USD

B level links receive an annual allocation of maximum 12,000 USD

C level links receive an annual allocation of maximum 1,500 USD

Please make sure that you submit your budget in USD. Indeed, in order to avoid further problems due to conversion rates, we will not accept any more budgets submitted in EUR.

The money will be sent to you as a grant. It will be sent to the Supporting Center for SRC Pairs and to the Mentor Center for the SRC Trios (unless explicitly requested and approved by the Mentor Center that the money be sent to the Supporting Center). It is then the Supporting or Mentor Center who distributes the money according to the incurred expenses. Please make sure to indicate the bank details of the Center of your link in the form below.

The SRC committee will judge the development of your SRC link based on the SRC objectives (that can be found in the manuals) and it is hoped your budget is prepared accordingly to address the below criteria:

Primary criteria:

1. Clinical staff training

2. Education

3. Upgrade of clinical services

Secondary criteria:

1. Community-orientation including evidence of participation in World Kidney Day

2. Clinical research activities at the EC

3. Relay of knowledge through regional, national and international meetings and publications

Guidelines to prepare your budget proposal:

-Budget amount:

The budget proposal should be consistent with the level you are applying to (for example if you are applying to level A, please submit a budget that amounts to 15.000 USD)
Please submit a budget in accordance to your allocated ISN SRC budget. If you wish to show all the activities and expenses planned for the year (also with non ISN SRC money), please use an annexe page

-Budget restrictions:

Please note that only 10% of your SRC budget can be allocated to travel supplement (so up to 150 USD for pairs applying to level C, 1,200USD for pairs applying to level B and 1,500 USD for pairs applying to level A)
The SRC grant is an educational grant and not a service grant. It is therefore highly discouraged to plan Budget for equipment (such as regular patient care or research laboratory equipment)

-ISN synergies with other ISN Programs:

The ISN offers 4 other very excitingPrograms: the Fellowship, the Educational Ambassador, the CME and the Research and Prevention Program.We would like to encourage you to use these programs to fund some of your SRC activities. As a SRC partnership, you have priority points when applying to these programs and this would allow you to use the SRC money for other educational activities. For instance, the Fellowship Program could fund short terms visits (2-6 months) from the EC to the SC/MC. Visit the ISN website for more information:

SRC Information

Emerging Center (EC):

Country:

Liaison Officer name:

Liaison Officer email address:

Supporting Center (SC):

Country:

SC Main contact name:

SC Main contact email address:

MentorCenter (MC)only for trios:

Country:

MC Main contact name:

MC Main contact address:

Current Category: ABCHB HC

Category in 2015: A BC

Supporting/ Mentor Center Bank Details

Bank Branch Name:

Bank Branch Address:

Post Code:City: Country:

Account holder name:

Account number:

SWIFT/BIC number:

IBAN number:

ABA number:

Other routing number:

Required communication:

Topics of SRC Activities

Please indicate the main focus of the SRC activities you would like to organize:

(Select only one option):

Acute Kidney Injury
Basic Science
Clinical Research
Epidemiology
Critical Care Nephrology
Chronic Kidney Disease
General Nephrology
Glomerular Disease
Hemodialysis
Hypertension
Nutrition and Hydration
Peritoneal Dialysis
Transplantation
Interventional Nephrology
Renal Pathology
Other:

Please indicate the secondary focuses of the SRC activities you would like to organize:
(Select a maximum of 3 options):

Clinical staff training

Multidisciplinary training exchanges between the EC and the SC (or MC), senior scholarship visits from the SC (or MC) to the EC

Planned visits from Emerging Center (EC) to Supporting Center (SC) or Mentor Center (MC)

VISIT 1
Breakdown of activity / Cost / Comments
Approximate Total Travel Cost
Approximate Total Accomodation Cost
Approximate Total Living Cost
Other (please explain)
Total in USD

Description of educational training plan

Name(s) of visitor(s) / Profession / Duration in weeks / Starting Date
1
2
3
VISIT 2
Breakdown of activity / Cost / Comments
Approximate Total Travel Cost
Approximate Total Accomodation Cost
Approximate Total Living Cost
Other (please explain)
Total in USD

Description of educational training plan

Name(s) of visitor(s) / Profession / Duration in weeks / Starting Date
1
2
3

Planned visits from Supporting Center (SC) or Mentor Center (MC) to Emerging Center (EC)

VISIT 1
Breakdown of activity / Cost / Comments
Approximate Total Travel Cost
Approximate Total Accomodation Cost
Approximate Total Living Cost
Other (please explain)
Total in USD

Description of educational training plan

Name(s) of visitor(s) / Profession / Duration in weeks / Starting Date
1
2
3

Please enclose a separate document should you wish to add another visit, further descriptions or details

Education

Local and regional CMEs, provisionof educational materials at the EC, attendance on training courses whilst on training attachments at the SC or MC, involvement with ISN Programs

PROJECT 1
Description of project
Item / Cost / Comments
Total in USD
PROJECT 2
Description of project
Item / Cost / Comments
Total in USD

Please enclose a separate document should you wish to add another visit, further descriptions or details

3. Upgrade of clinical services

Service development at EC - such as expansion of local and regional clinical nephrology facilities and services

PROJECT 1
Description of project
Item / Cost / Comments
Total in USD
PROJECT 2
Description of project
Item / Cost / Comments
Total in USD

Please enclose a separate document should you wish to add another visit, further descriptions or details

Other relevant activities

Including community orientation activities – such as WKD, clinical research and relay of knowledge

PROJECT 1
Description of project
Item / Cost / Comments
Total in USD
PROJECT 2
Description of project
Item / Cost / Comments
Total in USD

Total Budget Requested (as per all the above)

TOTAL USD: A level pairs: Maximum 15.000 USD

B level pairs: Maximum 12.000 USD

C level pairs: Maximum 1.500 USD

Signatures

Emerging Center Liaison Officer

EC Liaison Officer name:

Signature:

Supporting Center Liaison Officer

SC Main contact name:

Signature:

Mentor Center Liaison Officer(only for trio)

MC Main contact name:

Signature: