Scientific Abstract

Date Submitted:
Type of Grant: Bridge  Pilot & Feasibility Mentored Young Investigator  Research Off-Cycle
PROJECT TITLE:
APPLICANT INFORMATION
APPLICANT NAME: / HIGHEST DEGREE(S):
POSITION TITLE: / CURRENT INSTITUTION:
ACADEMIC RANK: / MAILING ADDRESS
DIVISION: / STREET ADDRESS
DEPARTMENT: / STREET (line 2)
E-MAIL ADDRESS: / CITY, ST, ZIP
TEL: / FAX: / COUNTRY
CO-INVESTIGATOR INFORMATION
NAME: / HIGHEST DEGREE(S):
POSITION TITLE: / CURRENT INSTITUTION:
ACADEMIC RANK: / MAILING ADDRESS:
DIVISION: / STREET ADDRESS
DEPARTMENT: / STREET (line 2)
E-MAIL ADDRESS: / CITY, ST, ZIP
TEL: / FAX: / COUNTRY
PROJECT INFORMATION
DATES OF PROPOSED PROJECT (MM/DD/YYYY) / PROPOSED BUDGET
FROM: / THROUGH: / TOTAL PROJECT BUDGET: / GRANT REQUEST:
$0 / $0
SIGNATURES & ASSURANCES
HUMAN SUBJECTS: /  No /  Yes / SIGNING OFFICIAL FOR INSTITUTION
Human Subjects Assurance No: / NAME OF OFFICIAL:
IRB No. or Status: / TITLE OF OFFICIAL:
DSMP Required? / NAME OF INSTITUTION:
ANIMAL SUBJECTS: /  No /  Yes / MAILING ADDRESS:
Animal Welfare Research No: / STREET ADDRESS
IACUC Status: / STREET (line 2)
Letter attached? / CITY, ST, ZIP
RECOMBINANT DNA /  No /  Yes / COUNTRY
Status: / INSTITUTION'S EIN #
Date: / INSTITUTION'S DUNS #
BIOHAZARDS /  No /  Yes / E-MAIL ADDRESS:
Adequate Protections Assured? / TEL: / FAX:
APPLICANT ASSURANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this application. / SIGNATURE OF APPLICANT: / DATE:
MENTOR ASSURANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with the grantor’s terms and conditions if a grant is awarded as a result of this application. I agree to mentor the Applicant in the scientific conduct of the project and provide oversight and training as described in the application / SIGNATURE OF MENTOR: / DATE:
SIGNING OFFICIAL ASSURANCE I certify that the statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with the grantor’s terms and conditions if a grant is awarded as a result of this application. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. / SIGNATURE OF SIGNING OFFICIAL: / DATE:

ABSTRACTS

PROJECT TITLE:
APPLICANT NAME:

Lay Abstract:

In 250 words or less, please describe for the lay public the nature of this work and its importance to developing a treatment or cure foralopecia areata.

Scientific Abstract:

In 250 words or less, please describe for the scientific community the nature of this work and its importance to developing a treatment or cure for alopecia areata.

One Page Description

In one page or less, describe the nature of this work and its importance to advancing understanding of and developing a treatment or cure for alopecia areata. Put this project in the context of what we know and what we need to know about alopecia areata and the autoimmune, skin and hair research landscape at this time.

RESEARCH PLAN

PROJECT TITLE:
APPLICANT NAME:

This section should describe the Research Plan in sufficient detail to permit effective review for scientific merit, achievability, relevance, significance and breakthrough potential. It is limited to 10 pages, including literature cited. Please refer to the Award Policies and Guidelines for details about what should be included in each section of the Research Plan.

A. Specific Aims and Hypotheses.

B. Background and Significance.

C. Preliminary Results.

D. Research Design and Methods.

E. Responsible Conduct of Research.

F. Consultant or Collaboration Arrangements.

G. Literature Cited.

Proposed Progress Report Milestones

Clearly articulate measurable milestones for 4 months, 8 months and one year.

Milestones that will be met before 4Month progress report:

Milestones that will be met before 8Month progress report:

Milestones that will be met before Final (12Month) progress report:

DETAILED BUDGET

(Reproduce this page for each year of funding)

PROJECT TITLE:
Year: / From: / Through:
Personnel (Applicant Organization Only) /

TOTALS

A / B / C / D / E (C*D)
Name / Position Title / % of time to this project / Total Salary / Salary request for this project
Subtotals
Supplies

Subtotal

Travel

Subtotal

Animal Purchase and Care

Subtotal

Patient Care Costs

Subtotal

Other Expenses

Subtotal

TOTAL COSTS

BUDGET JUSTIFICATION

(Reproduce this page for each year of funding)

PROJECT TITLE:
Year: / From: / Through:

Provide justification by major budget categories. Describe how this award money will be used toward the total cost of the research and how any additional money needed to complete the research will be obtained.

QUESTIONNAIRE

What percent of effort will the principal investigator(s) be spending on this project?

What other projects are you working on? What percent of effort are you spending on those projects? How will the research proposed in the Application be accomplished in conjunction with your other projects?

Have you had previous funding from NAAF? If so, list date(s), amount(s), and project title(s).

Has your previously funded work from NAAF been published? Please list titles, publications and dates of publications.

Is your organization’s human research protection program accredited by the Association for the Accreditation of Human Research Protection Programs (AAHRPP)? If no, by when does your organization plan to seek accreditation?

OTHER CURRENT AND PENDING SUPPORT

PROJECT TITLE:
APPLICANT NAME:

Describe all current and pendingfunding that the Applicant and laboratory receiveor expect to receivewhether or not it is related to the research project proposed for this award. No page limit to this section.

Source: ______

Amount: $ ______from (start date) ______to (end date) ______

Relationship to the research project proposed for this award: ______

______

PREVIOUS TRAINING AND EXPERIENCE AND FUTURE PLANS

PROJECT TITLE:
APPLICANT NAME:

Provide summary of research and clinical fellowship training, clinical and research experience and future plans – including the reasons for entering fields related to alopecia areata research. Demonstrate interest and commitment to alopecia areata research and care, and to pursuing a career in academic medicine or research. Not to exceed 5 pages.

BIOGRAPHICAL SKETCH

PROJECT TITLE:

This Biosketch is for  Applicant Other key project personnel

Name:

Professional Title:

Date of Birth:

EDUCATION: (begin with baccalaureate and include postdoctoral training)

Institution and Location / Degree / Year Conferred / Scientific Field

RESEARCH AND PROFESSIONAL EXPERIENCE

Starting with present position, list in reverse chronological order employment, experience and honors.

PUBLICATION REFERENCES

List complete reference to all publications during the last three years and any previous publications relevant to this application. Whether you use this form or an NIH-style biosketch, clearly mark all publications relevant to this application. Do not exceed 3 pages.

NAAF 2015Application Page 1 of 14