ESSM Research Grant Application Form
TITLE OF STUDY:
Name and surname of the principle investigator:
Current position:
Address:
E-mail:
Phone:
Fax:
Name and surname of the co-investigator:
Current position:
Address:
E-mail:
Phone:
Fax:
Name and surname of the co-investigator:
Current position:
Address:
E-mail:
Phone:
Fax:
Name and surname of the co-investigator:
Current position:
Address:
E-mail:
Phone:
Fax:
Proposed start date:
Proposed end date:
Duration (in months):
SUMMARY (max 300 words):
Please summarise the background, aims, methods and expected impact in simple terms
BACKGROUND (max 500 words):
AIMS (max 200 words):
METHODS (max 500 words):
REFERENCES:
IMPACT (max 300 words):
What would be the impact of the project on sexual medicine field when it is successfully completed? Please explain how your project fits to the specific call
ETHICAL AND REGULATORY PERMISSIONS:
Please explain the ethical and regulatory permissions already obtained or to be obtained for (if applicable):
1) Animal research
2) Human tissue
3) Research with human participants
If the permissions have not been obtained already, please give timelines of when they are expected to be obtained and how obtaining such permissions will affect the overall project timelines.
BUDGET:
Please give a detailed and itemized budget, see T&C for eligible and ineligible costs
PROJECT PLAN:
Please give a detailed plan (preferably include a Gantt chart) for the project with dates and durations
ATTACHMENTS:
Please attach:
CV of the PI including list of all peer reviewed publications
Copies of ethics and regulatory permissions
Any figures or tables
SIGNATURES:
I have read and understood the ESSM Research Grants Terms and Conditions and agree that if my application is successful, I will abide by them. I shall be actively engaged in, and in day-to-day control of this project.
Principle Investigator
Name, surname:
Signature:
Date:
I confirm that I have read this application and that, if granted, the work will be accommodated and administered in this Department/Institution in accordance with the ESSM’s Research Grants Terms and Conditions. I confirm that the resources necessary to support this research are available within the Department/Institution.
Head of Department
Name, surname:
Position:
Signature:
Date:
Administrative Authority:
Name, surname:
Position:
Signature:
Date:
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