Print Form
COMMONWEALTH OF VIRGINIA
Alzheimer’s and Related Diseases Research Award Fund
APPLICATION FORM FOR PROPOSAL
Deadline: April 1, 2016
PART I
1.Principal Investigator:
Position:
Department/School:
Organization:
P.I.'s Mailing Address:
Phone, FAX#, & e-mail:
2.
Co-Investigator(s):
Project Staff:
3.
Title of Proposal:
4.
Amount Requested (not to exceed $45,000):
Authorized Official:
5.
Position:
Address:
Phone, FAX #, & e-mail:
6.
Signatures (Use Blue Ink)
I certify that the statements herein are true and complete to the best of my knowledge, and accept
the obligation to comply with the contractual terms and conditions of the Alzheimer's and Related
Diseases Research Award Fund (ARDRAF) if a grant is awarded as the result of this application.
Principal Investigator_______________________________
Date__________
Authorized Official_________________________________
Date__________
Virginia Center on Aging/School of Allied Health Professions/ Virginia Commonwealth University
P.O. Box 980229/Richmond, VA 23298-0229/(804) 828-1525
7.
Other Support
Note: Incomplete, inaccurate, or ambiguous information about Other Support could lead to significant
delays in the review and funding of proposals. By signing and dating the cover page of this application,
the principal investigator and authorized official certify that any changes in Other Support information
after the application has been submitted will be reported immediately to the administrator of the
Alzheimer's and Related Diseases Research Award Fund.
a.
b.
For each person participating directly on the project (the principal investigator, coinvestigator(s), and project staff named on the application cover page), in the space below
list all currently active support from grants or contracts, all support from grants or
contracts for projects that have ended within the last three years, AND all applications or
proposals pending review or award, whether related to this application or not. Please also
include the status (active, previous, or pending), title, amount, funding period, funding
source and role (including % of effort) of the person involved. Clearly indicate whether
there is any scientific or budgetary overlap with the currently proposed project. Be sure to
attach a copy of the specific aims for active, previous, or pending awards, grants, or
contracts as an appendix to this application. (Use continuation pages, if needed).
Is the proposed ARDRAF project being supported in part or in full, or has it been
supported previously, by another grant program, research contract, or any other source of
funds? Yes
or No . If "yes," describe any scientific or budgetary overlap with the
currently proposed project. (Use continuation pages, if needed).
8.
Are human subjects involved in the proposed research? Yes
or No .
If "yes," include a copy of the research synopsis/narrative description/grant
application summary form/grant information form submitted to the Institutional
Review Board (IRB) as an appendix to your proposal. Is evidence of IRB approval to
begin enrolling subjects in the proposed project also attached? Yes
or No .
If approval is pending, please indicate the date when a decision will be made
and the grant number assigned to the pending IRB application
If the pending IRB protocol is being approved under another grant,
provide the protocol number as well as the grant number and title
Protocol #
Title
Grant #
Note: It is the responsibility of the applicant to forward evidence of IRB approval to
begin enrolling subjects in the proposed project no later than May 15, 2016. Certification
of IRB grant review or preliminary IRB approval is not sufficient. The Awards
Committee may choose not to consider applications that lack evidence of IRB
authorization to begin enrolling subjects.
9.
Are laboratory animals involved in the proposed research? Yes
or No .
If "yes," include a copy of the research synopsis/abstract of experimental
purpose/summary of the study aims submitted to the Institutional Animal Care and Use
Committee (IACUC) as an appendix to your proposal. Is evidence of approval also
attached? Yes
or No .
If approval is pending, please indicate the date when a decision will be made
and the grant number assigned to the pending IACUC application
If the pending IACUC protocol is being approved under another grant, provide the
protocol number as well as the grant number and the title.
Protocol #
Title
Grant #
Note: It is the responsibility of the applicant to forward evidence of approval no later
than May15, 2016. The Awards Committee may choose not to consider applications that
lack evidence of IACUC authorization.
10.
Does the proposed research involve the use of biohazardous substances (e.g., recombinant
DNA or human materials, i.e., blood, cell lines)?Yes
or No .
If “yes, include a copy of the biosafety approval form or memorandum of
understanding submitted to the Institutional Biosafety Committee as an appendix.
Is evidence of approval also attached? Yes
or No
If approval is pending, please indicate the date when a decision will be made
and the application number assigned to the pending IBC application
If the pending IBC application is being approved under another grant, provide the
protocol number as well as the grant number and title.
Protocol #
Title
Grant #
Note: It is the responsibility of the applicant to forward evidence of approval no later
than May 15, 2016. The Awards Committee may choose not to consider applications that
lack evidence of IBC authorization.
11.
Is this a resubmission of a previous ARDRAF proposal? Yes
or No .
If yes, please summarize any changes you have made in this revised proposal. (Use continuation
pages, if needed).
12.
If the Principal Investigator or Co-Investigators have been previously funded by the ARDRAF,
please list year(s) and title of project(s) below, and in the Appendix attach any abstracts for
presentations, publications, etc., which resulted from your previous award(s).
13.
If the Principal Investigator or Co-Investigators have been previously funded by the ARDRAF,
did the pilot data strengthen any grant applications that have been subsequently funded or lead to
any related contracts supporting your work? If yes, please list. the funding source, project
title, funding period, status (completed, active, or pending), and the exact dollar amount of the
award or contract (specify direct costs only).
PART II. BUDGET
Itemized
Contributed
Resources1
Amount Requested
from ARDRAF
Personnel2
(Names, title(s), % of effort)
Subtotal $
Personnel
Subtotal $
Personnel
Fringe
(Identify organizational fringe rate)
Subtotal $
Fringe
Subtotal $
Fringe
Supplies (Specify)
Subtotal $
Supplies
Subtotal $
Supplies
Travel
Subtotal $
(Dissemination travel limited to $1000) Travel
Subtotal $
Travel
Equipment
(limited to 10% of total award)
Subtotal $
Equipment
Subtotal $
Equipment
Other (Specify)
Subtotal $
Other
Subtotal $
Other
TOTAL
CONTRIBUTED $
1
TOTAL
REQUESTED $
Include letter of commitment from source of in-kind contributions as an appendix to this application
Tuition reimbursement and graduate student stipends are not allowed. Students may be supported by the ARDRAF as hourly
employees, however.
2
PART III. BUDGET JUSTIFICATION
List percent of effort on project along with the roles and responsibilities of each person participating directly in
the project (the principal investigator, co-investigator(s), and project staff listed on the application cover page),
regardless of whether salary support has been requested. Explain and justify requests for equipment, unusual
supplies, travel reimbursement, and other expenses. (Use continuation pages, if needed).
PART IV. ABSTRACT
Please provide a non-technical abstract of the proposed project (250 words or less):
PART V. PROJECT DESCRIPTION
The project description is limited to ten, single-spaced, (or 20 double-spaced) 8 1/2" x 11", typewritten pages (does not include references, initial application pages, vitae, or appendix material). All
application pages should be single-sided and numbered consecutively. Type must be standard size
(10-12 points or 15 characters per inch). All margins must be at least 3/4". Applications not meeting
these requirements will be returned without review, or may be subject to deferral. The project
description should generally follow the format below (with approximated page length suggestions):
A.
Specific aims - List the research objectives/hypotheses and what the project is intended to
accomplish (1 page or less suggested)
B.
Background and significance - Cite the literature pertaining to the proposed
investigation (including the applicant's previous work where appropriate), the importance
of the research proposed, and the rationale/need for conducting the work. (2 pages or less
suggested).
Note: If you have been previously funded by the ARDRAF, clearly explain any
relation between the previous work and the present proposal.
C.
Experimental design and methods - Describe the research design and procedures to be
used; the means by which the data will be collected, analyzed, and interpreted; and the
possible outcomes of the study with reference to any potential limitations of the
procedures. Please also specify the alternative approaches or contingency plans that may
be employed to achieve the specific aims (5-7 pages suggested).
Note: Thoroughly describe any new methodology and indicate its advantage over
existing methodologies. Otherwise, laboratory studies should employ acceptable
methods that are appropriately referenced, and other experimental studies should
employ standardized assessment instruments with references and specification as
to validity and reliability. Copies of proposed assessment tools should be included
as an appendix to this application.
D.
Physical Facilities - State the adequacy and appropriateness of all laboratory, clinical,
animal, computer, or office facilities to be used by the project (1 paragraph suggested).
E.
Schedule - Provide a proposed time-table for completing project activities (1 paragraph
or chart suggested).
F.
Appropriateness for Funding - Explain why the proposed project is appropriate for
funding by the ARDRAF (1 page or less suggested).
Note: Refer to the goals of the Award Fund as given on the first page of the
ARDRAF Guidelines.
Next Steps - Describe how the proposed project relates to the investigator's broader research
program and plans for securing future funding to support the next steps (1/2 page or less suggested)
G.
PART VI. LITERATURE CITATIONS
References in the text are shown by citing in parentheses either the authors’ surnames and the year
of publication (if the reference list is alphabetized) or the number assigned to the citation in a
sequential reference list. A complete list of references should be provided at the end of the project
description. Do not scatter them throughout the text as footnotes. For periodicals include article
authors, date of publication, article title, journal title, volume and series number, and inclusive page
numbers. For books, include book authors or editors, date of publication, book title, name of the
publisher, and the city where the publisher is located. For references to articles or chapters in an edited
book, also include the article or chapter authors, article or chapter title, and the inclusive page numbers
PART VII. BIOSKETCHES
Attach copies of the biosketches for each person participating directly on the project (the
principal investigator, co-investigators, and project staff listed on the application cover page).
Biosketches should be no longer than 2 pages for each person, including selected publications.
PART VIII. PEER REVIEWER
As part of the "Review Process" described on Page 3 of the ARDRAF Guidelines, an independent
reviewer recommended by the applicant reviews each proposal. Contact three individuals who are
qualified to review your proposal and secure their prior consent to participate in the 2016 review
process. If a peer review is not received as a consequence of the applicant's failure to secure prior
consent, the review of an application can be easily disadvantaged. Peer reviewers should be informed
that we try to allow approximately one month for the completion of reviews and that the due date is
generally around the middle of May. Applicants shall seek to involve peers who can provide an
objective review. Peer reviewers shall NOT be from the home institution or agency of the Principal or
Co-investigators, and shall NOT be a co-investigator or collaborator on any active or pending grantfunded project, co-author, student/trainee, or former mentor/advisor. Please submit the names, mailing
addresses, telephone numbers, and e-mail addresses of three individuals who have agreed to review your
proposal and indicate why each would be an appropriate reviewer. One of the three individuals will
be selected by the ARDRAF administrator to receive a copy of your proposal and the review form.
Completed review forms will be returned to the Virginia Center on Aging for use by the Awards
Committee and kept in confidence. Applicants may request summarized feedback from anonymous
reviewers and the Awards Committee after the awards have been made.
PART IX. APPENDICES
Be sure to include a copy of the Institutional Review Board application (and evidence of approval,
if review has been completed). Appendix materials should be kept to a minimum. Include letters of
commitment/collaboration/cooperation (especially letters verifying the sources for cell cultures) and
verification of in-kind support. Letters of commendation or general support should not be solicited.
APPLICATION DEADLINE: Hard copy sent by carriers who date stamp on or before the due date
is required, with an additional electronic e-mailed copy sent by the close of business April 1, 2016.
Submit the SIGNED ORIGINAL (NO STAPLES) AND 3 COPIES to:
Constance L. Coogle, Ph.D., Administrator
Alzheimer's & Related Diseases Research Award Fund
Virginia Center on Aging
Virginia Commonwealth University
P.O. Box 980229; Richmond, VA 23298
for door to door delivery: 730 E. Broad St., 2nd floor, Rm. 2088
Richmond, VA 23219
804/828-1525
ccoogle@vcu.edu
Application Submission Checklist
The following elements are reminders of steps and documentation that must be included when your application is submitted.
Applicants should complete and sign the checklist, then include it as the last page of their applications. Incomplete
applications or those that do not adhere to the specifications given in this Application Form and the ARDRAF
“Guidelines for Submitting Research Proposals” may be returned without further consideration.
PART I (1.-5. on face page of Application)
6.
Signatures - Required of Principal Investigator and Authorized Official (in blue ink)
7a.
Other Support – Specific aims and other requested information for all active and pending
support for Principal Investigator, Co-Investigators, and Project Staff
7b.
Statement of scientific and budgetary overlap with the proposed project
8.
Human IRB research synopsis, approval notification, pending date for decision, and
grant/protocol numbers assigned
9.
IACUC research synopsis, approval notification, pending date for decision, and
grant/protocol numbers assigned
10.
Biosafety approval granting authorization for your laboratory
11.
Summary of changes for resubmissions
12.
List of publications/presentations related to previous ARDRAF-funded projects
13.
Subsequent funding related to previous ARDRAF-funded projects
PART II.
Budget (Letters of commitment from sources of in-kind contributions)
PART III.
Budget Justification (% effort, roles, & responsibilities for Principal Investigator, CoInvestigators, and Project Staff
PART IV.
Non-Technical Abstract
PART V.
Project Description (adhering to the page limitation for Items A. - G.; i.e. 10 single-
spaced, or 20 double- spaced).
PART VI.
Literature Citations
PART VII.
Curriculum Vitae (include 2-page maximum length vitae for Principal Investigator, CoInvestigators, and Project Staff)
Peer Reviewer (include names, mailing addresses, telephone numbers, and e-mail addresses
of three individuals who have agreed to review your proposal and indicate why
each would be an appropriate reviewer)
COPIES PREPARED: (SUBMIT ORIGINAL AND 3 COPIES OF FULL PROPOSAL WITH APPENDICES)
PART VIII.
date stamped by the due date with an e-mailed copy by the close of business (ccoogle@vcu.edu)
Principal Investigator
Date