Pilot grant application, 2016
Pilot grant application
2016
Stichting MS Research
P.O. Box 200
2250 AE Voorschoten
The Netherlands
E-mail : onderzoek@msresearch.nl
Tel.
: +31-71-5 600 500 or +31-71-5 600 508 (research coordinator)
Our project number: 16 – .... MS
Please send an electronic version (Word-file) and 1 signed hard copy to the addresses above
Please use arial 10, single line spacing
Extra attachments will not be accepted
Basic details
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Name applicant, title(s)
Position
Institute
Department
Postal address
Zip code, city
Telephone
E-mail
Title proposed project
English
Dutch
Brief summary of research
question and study design
(300 words max.)
Host institution
(if applicable)
Relevance for MS
Mr/Ms, Prof./Dr.
Research proposal
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Background & research
questions
Background (500 words)
Hypothesis (100 words)
Objectives (100 words)
Pilot/preliminary data
if applicable (200 words)
Max. 25 references
Supplemental information
is not allowed
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Pilot grant application, 2016
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Study design & work plan
(1000 words)
Planning subsequent years
(200 words and/or scheme)
Project group
(*fte involved in this project)
Embedding & cooperation
Relationship of this grant
proposal with other studies
financed by the Dutch MS
Research Foundation
Has this grant proposal
been submitted to the
Dutch MS Research
Foundation previously?
If yes:
 What was the project
number of this proposal?
 What are the differences
between this and the
previously submitted
application?
Has this grant proposal
been submitted elsewhere?
Title(s) and name
Discipline
yes/no
Human subjects, laboratory animals, biohazards
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a.
b.
c.
d.
Will experiments be performed with:
Patient material
Healthy volunteers
yes/no
Patients
yes/no
If yes:
 Number of
volunteers/patients
 Type of research
 Does the proposed study
yes/no/requested
have the approval of a
commission regarding
experimental subjects?
Experimental animals
Use of experimental animals
yes/no
If yes:
 Kind of animals
 Number of animals needed
per year
 Nature of intervention
 Justification for the number
of animals required
 Does the proposed study
yes/no/requested
have the approval of a
commission regarding
experimental animals?
Brain material
Use of brain material
yes/no
Biological risks
Recombinant DNA
yes/no
If yes:
 Class
Radiation (wave and/or
yes/no
particle)
Radioactive isotopes
yes/no
Pathogenic micro-organisms
yes/no
Are required grants, permits
yes/no
and facilities available?
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Employed by
Fte*
Pilot grant application, 2016
Finances and justification
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Justification
Personnel, expertise,
discipline and time frame
Materials and/or patients
Other
Financial support from sources other than the Dutch MS Research Foundation:
Own institute
Others
Personnel and budget requested **
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Personnel
Function
Lump sum category
(delete whichever
is not applicable)
Fte
Amount of months
Costs (€)
Personnel
Materials/patients
Other:
Scientific staff
Technical staff
promovendus/wetenschappelijk
medewerker
NWP niveau 1/niveau 2/niveau 3
Total costs (€)
Signatures
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Responsible administrator of
organisation
Project leader
Name
Signature
** According to the grant directives (2015)
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Pilot grant application, 2016
Addendum
Justification for the requirement of experimental animals *
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a.
b.
c.
What are the reasons that this research…
…cannot be performed without experimental
animals (Replacement)?
…cannot be performed with fewer animals
(Reduction) or with less distress and discomfort
for the animals (Refinement)?
…cannot be performed with a lower species of
animals?
Justification for the requirement of EAE animal models *
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What are the reasons that this research
requires the use of an EAE-animal model?
* If the grant proposal does not require experimental animals, this addendum can be deleted from the application
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