Return This Completed Form To: Sunanda Markus, Grants Adminstrator, At

RESEARCH GRANT

CHANGE IN STATUS FORM

Return this completed form to: Sunanda Markus, Grants Adminstrator, at

If, during the course of your award, you are unable to meet the terms of the award, then you are obliged to inform Mind and Life within 30 days so that appropriate action may be taken. Because stipend payments are made in advance, it may be determined that a portion of the stipend must be returned. If this is the case, you will be informed of the amount that must be repaid, the basis for the calculation, and the date by which repayment must be made.

NAME:______

DATE:______DATE AWARDED: ______

TITLE OF PROJECT:______

REASON FOR FORMAL CHANGE IN STATUS REQUEST:

(check appropriate box and fill out additional information)

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REQUEST FOR EXTENSION (I am encountering difficulties or significant delays in carrying out my research as described in my application). Each project will ideally be completed within two years but no longer than three years. If you are unable to complete the research within two years, you must submit a brief but detailed written request explaining why the extension is necessary and when you anticipate the project will be completed. These requests for extension of time will be considered on a case-by-case basis.

Extension requested until date:______

Describe the reason an extension is needed, including progress you have made until now, problems encountered, and strategy to move forward (250 words or less):

MODIFICATION OF PROTOCOL (I need to redesign/modify my research project). Examples of significant changes include but are not limited to: change in original goals of project, change of population of subjects, change in methodology.Summarize changes in protocol below (250 words or less):

INSTITUTION/ADVISOR CHANGE (I am changing institutions or advisors during the course of my research). The 1440 Awards are made to the institution where the named Fellow is conducting his or her research. In the event that the Fellow or Mentor leaves that institution, the award is not transferable without prior approval of the 1440 Awards Selection Committee. If this request for transfer of funds is not approved, any unused funds must be returned to Mind and Life within 30 days. Please attach a new letter of support from the new (or same) mentor to support the proposed research in the new context, and IRB documentation from new institution (if applicable).

Original Institution/Advisor:______

New Institution/Advisor:______

Please explain the context surrounding the change and how those changes might affect the proposed research (250 words or less):

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