Full Proposal 2018 Award Cycle FELLOWSHIP PROJECT AWARD€¦ · Web viewAuthor: Angela Bretagne...

RESEARCH FOCUS: CORRELATION BETWEEN RETINAL ANATOMY AND

FUNCTION IN RETINAL DISEASE

October 2019 | PP-EYL-GB-0419

Letter of Intent2020 Award Cycle

RESEARCH AWARD

ContentsINSTRUCTIONS..............................................................................................................................................3

GOAP CONTACT............................................................................................................................................3

RESUBMISSION INSTRUCTIONS.................................................................................................................4

HOW DID YOU HEAR ABOUT THE PROGRAM?..........................................................................................4

ELIGIBILITY FOR AWARD..............................................................................................................................5

APPLICANT DETAILS.....................................................................................................................................5

QUALIFICATIONS .......................................................................................................................................7

RESEARCH AWARD ABSTRACT..................................................................................................................8

RESEARCH PROJECT OUTLINE...............................................................................................................8

PROJECT DETAILS.....................................................................................................................................8

FUNDING REQUESTED..............................................................................................................................9

DECLARATIONS.............................................................................................................................................9

FOR OFFICIAL USE ONLY NAME Click or tap here to enter text.NUMBER Click or tap here to enter text.SIGNATURES ☐

WORD COUNTS ☐

APPLICANT REAPPLYING Choose an item.

ALL SECTIONS COMPLETED ☐

CHECKED BY Click or tap here to enter text.

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DISCLAIMER: The Global Ophthalmology Award Program (GOAP) is fully sponsored by Bayer. The Grant Review and Awards Committee (GRAC) evaluates and ranks the GOAP applications and convenes once per year to finalise the list of awardees. Bayer organises the process but is not involved in the application evaluation process, nor in the selection of awardees.


INSTRUCTIONS

Please carefully read the guide to submitting an application on the GOAP website before proceeding with your application, paying particular attention to the following:• Eligible projects should have a duration of 1 year from receipt of funding. Justified exceptions

to this guideline can be discussed on a case-by-case basis. A maximum budget of up to US $50,000 is available for the majority of cases

• Applicants must complete all sections of this form, including stating word counts where required. If a section does not apply to you, please write or choose ‘not applicable’ (N/A)

Priority will be given to projects relating to the 2020 research focus of the correlation between retinal anatomy and function in retinal disease

• Two applications from the same group will not be accepted, regardless of whether they are for the different award categories (ie, the Research Award and the Fellowship/Training Award)

• PhD projects will not be considered for this award

• Applicants who are members of a commercial entity/company will not be considered for this award

• Upon completion of this proposal form, please email it to the GOAP Program Secretariat (managed by the agency ApotheCom on behalf of Bayer Consumer Care AG, Switzerland) at: [email protected]

• If you are resubmitting an application, please follow the instructions below

• Submission deadline is 31 January 2020

GOAP CONTACT For any questions, please refer to the GOAP secretariat:

Bernadette Stansfield [email protected] +44 (0) 207 340 6636

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mailto:[email protected]

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RESUBMISSION INSTRUCTIONSIf you are submitting an application that was previously submitted to GOAP, please tick the box below and select the year that you last submitted the application:

I am resubmitting an application ☐

I previously applied for funding from GOAP in

Choose an item.

In addition, please attach a letter covering the following points:

Describe how you have addressed each feedback point previously provided by the Program Secretariat

If a feedback point has not been addressed, please explain why this is the case

Please tick the box to confirm that you have attached the letter

☐

How did you hear about the program? Choose an item.

HOW DID YOU HEAR ABOUT THE PROGRAM?If other, please state how you heard about GOAP

Click or tap here to enter text.

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ELIGIBILITY FOR AWARDPlease complete the below section to confirm your eligibility for this award.

Have you received your ophthalmology specialist qualification within the past 10 years or are you currently training towards receiving it?PhD applicants: Have you received your PhD qualification within the past 10 years?

Choose an item.

If you answered ‘No’ to the above question, please detail any mitigating or extenuating circumstances that should be taken into consideration (e.g. career break due to parental leave or family responsibilities)


Please state the number of vision science-related publications (PubMed-indexed) you have (co-)authored to date.


APPLICANT DETAILSApplicant information Title Click or tap here to

enter text.Full name Click or tap here to

enter text.Phone Click or tap here to

enter text.Full address Click or tap here to

enter text.Email Click or tap here to

enter text.Employer institute informationYour current (home) institution:


Country Click or tap here to enter text.

Your current position within this institution/organisation:

Choose an item. (If Other, please provide details in the space below)Click or tap here to enter text.

Name of institute/employer to which funding will be awarded


Type Choose an item.

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Full address Click or tap here to enter text.

Institutional Profile File number: (Write ‘not applicable’ if unknown)


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QUALIFICATIONS (This section should not exceed 5 pages)

Education/training:Please provide details of your professional education in the relevant spaces provided below. Begin with baccalaureate or other initial professional education, such as nursing; include postdoctoral training and residency training if applicable. It is important to indicate the dates of Ophthalmology training (e.g. start of residency and obtention of specialisation) and of retinal subspecialty training (e.g. start and end dates of subspecialisation) as applicable. Add/delete rows as necessary.

Institution and location:

Degree:(If applicable)

Start and completion dates:

(MM/YYYY)

Field of study:

Personal statement:

Positions and honours:In chronological order, please list any positions held prior to your current position. Provide details of any honours obtained, including present memberships on any advisory committees. (MAXIMUM 10 EXAMPLES)

Contributions to science:In chronological order, please provide a list of your key publications along with a summary of importance. Do not include publications submitted or in preparation.(MAXIMUM 10 EXAMPLES)

Additional information: Research support and/or scholastic performance. Please add any research support you have been awarded. For Scholastic Performance, please list the undergraduate/graduate courses completed and the corresponding year and grade for each course as well as any relevant professional courses.

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RESEARCH AWARD ABSTRACTTitle of proposed project (max. 100 characters, including spaces)


Duration of project Choose an item.

RESEARCH PROJECT OUTLINE RESEARCH SECTION (500 words)

Describe the rationale for your proposed project and the justification for the proposed methods, including power calculations for justification of your sample sizes, where appropriate.Include any potential pitfalls of the methods and suggest alternative strategies.Describe any future work anticipated from completion of this project, especially with regard to care of patients with retinal disorders.If necessary, please include a reference list, which does not contribute towards the word limit.

Please enter research project outline here: Click or tap here to enter text.

Please specify the word count (max. 500 words): Click or tap here to enter text.

PROJECT DETAILSIs the research project part of a larger project? Choose an item.

(If yes, please ensure you provide a well-defined sub-project for this application

Please state the percentage of your time that will be dedicated to this project:

Click or tap here to enter text. (Before submitting your application, please ensure that it is achievable to complete your project in the proposed time frame)

Please provide the name and title of the principal investigator:


Please provide the name(s) and title(s) of any co-investigators:


Is this research ongoing? Choose an item.

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Has this work received ethics approval? Choose an item.

Has funding been provided from other sources?

Choose an item.(If yes, please provide details in the space below)Click or tap here to enter text.

FUNDING REQUESTEDA maximum budget of up to US $50,000 is available for the majority of cases. Additional funding will be considered but must be justified. Budgets should be realistic and appropriate to the scope of work being proposed. Payment will be made to the awardee’s institution only.

US $ Click or tap here to enter text.Please write the full amount in words in the space provided below:


DECLARATIONSAPPLICANT ASSURANCE

I certify that the statements herein are true, complete, and accurate to the best of my knowledge.

☐

Application signature

PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR ASSURANCE

I certify that the statements herein are true, complete and accurate to the best of my knowledge.

☐

Principle Investigator/Program Director full name and signature

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Full Proposal 2018 Award Cycle FELLOWSHIP PROJECT AWARD€¦ · Web viewAuthor: Angela Bretagne...

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