CONFIDENTIAL
Project Application Form
Chemelot InSciTe Project Application Form
Version 5.0, 2015-08-06
CONFIDENTIAL
Chemelot InSciTe Biomedical Application Form
Document data
Document key information
1.00
Title
Version
Owner
Status
Date
2014-01-27
Chemelot InSciTe Project Application Form Biomedical materials
4.00
Danielle Curfs
final
2015-07-28
Document change history
Version Date
Author
Section
Nature of change
2.00
2.01
3.00
4.00
5.00
all
all
all
all
all
Revisions in lay-out and wording
Revisions in lay-out and wording
Change of lay-out
Update
update
2014-04-15
2014-11-07
2014-11-07
2015-07-28
2015-08-06
D. Curfs
D. Curfs
E. Staring
D. Curfs
D. Curfs
Related documents
Document name
Chemelot InSciTe Instructions for
Biomedical project proposals
Chemelot InSciTe Financial
Guidelines
Chemelot InSciTe Budget Sheet
Chemelot InSciTe IP guidelines
Chemelot InSciTe Project
Agreement
Date
Description
Owner
2015-07-28
D. Curfs
2015-04-15
Instructions for submitting a biomedical
project proposal
InSciTe financial guidelines
2015-06-26
2014-11-06
2015-07-01
Budget sheet for InSciTe projects
IP guidelines for InSciTe projects
Project Agreement
M. Jeuken/
E. Staring
M. Jeuken
E. Staring
E. Staring
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Chemelot InSciTe Biomedical Application Form
Introduction
This project application form is designed for project proposals for the biomedical program of
Chemelot InSciTe. Applicants submitting a project proposal are strongly advised to familiarize
themselves with the Chemelot InSciTe objectives and additional information such as the
organization, IP guidelines, budget sheet, financial guidelines etc. The questions in the
project proposal form are designed to provide the applicants with the possibility to explain in
detail why a project fulfils the criteria and should be executed within InSciTe.
Each project application form is linked to a Project Leader (PL) and his/her email address. For
each project, we ask the Project Leader to submit this form after reaching agreement with all
applicants.
Concerning the budget, an overview of the main project costs and contributions is required
when submitting this form. Additionally, the details of the project budget must be provided in
the project budget sheet. The project application form should be submitted together with the
project budget sheet.
Questions regarding the application of a project proposal or this form can be directed to
Danielle Curfs, program manager biomedical Chemelot InSciTe, preferably via email at
danielle.curfs@chemelot-inscite.com
Use this document to submit your proposal. Your data should be added in the blue boxes.
The required font type and size is Arial 10 pt. Line spacing is single.
Submission deadline for the 2nd wave of project proposals is 6 November 2015.
Completed forms are to be sent to Chemelot InSciTe by e-mail to danielle.curfs@chemelotinscite.com
As a formal requirement, a signed hardcopy of this form together with the budget sheet are
required in order to confirm submission of a proposal. The signed hardcopy should be send
to:
Chemelot InSciTe
p/a Danielle Curfs
Urmonderbaan 20F
6167 RD Geleen
The Netherlands
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Chemelot InSciTe Biomedical Application Form
I.
GENERAL INFORMATION
This section of the project proposal gives information on title, project participants and subsidy
possibilities. Max 2 A4.
1. Project title1
PLEASE ENTER HERE A PROJECT TITLE OF MAX 2 LINES
2. Project acronym
Please enter here a project acronym of max 30 characters
3. Contact information of the Project Leader (PL)
Name
Please enter here the person acting on behalf of the Project Leader
Name of organization
Please enter here the organization being the PL
Address
Please enter here Street and number
Please enter here Postal Code and City
Telephone number
Please enter here the telephone number
Email address
Please enter here the e-mail address
4. Contact information of the Participants’ Representative (PR)
Name
Please enter here the person acting on behalf of the Participants’
Representative
Name of organization
Please enter here the organization being the PR
Address
Please enter here Street and number
Please enter here Postal Code and City
Telephone number
Please enter here the telephone number
Email address
Please enter here the e-mail address
5. Applicants
Name
enter name
enter name
enter name
enter name
enter name
enter name
Organization name
enter organization
enter organization
enter organization
enter organization
enter organization
enter organization
Organization type
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Email address
enter e-mail
enter e-mail
enter e-mail
enter e-mail
enter e-mail
enter e-mail
1
In order to prevent the use of different fonts and point sizes, and to maximize the amount of information
presentable, the number of char. is approximately 1 page A4 is 4,000 char. (ca. 600 words).
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Chemelot InSciTe Biomedical Application Form
Please be aware that for project applications in this this second wave, all projects must secure
additional funding in addition to InSciTe funding, e.g. by participation of third parties (i.e. nonFounding Fathers) and/or by financial contributions from subsidies or other funding agencies.
6. Submission for other grant applications
Have you submitted an application to or received a subsidy for this project or a part of this project?
(e.g. from a government ministry, the “Netherlands Organization for Scientific Research” (NWO), Horizon 2020 etc.)
Choose yes/no
Grant name
Grant description
Please enter here the grant name
Please enter here a grant description, max 10 lines
Amount [k€]
Please enter the amount of the subsidy in k€
If you have submitted an application or received a subsidy for this project or part of it, was this as part
of the InSciTe project portfolio?
Choose yes/no
7. Future opportunity for other grant applications
Are you intending to submit this project or a part of this InSciTe project for external funding?
Choose yes/no
Grant name
Please enter here the grant name
Grant description:
Please enter here a grant description, max 10 lines
approach/strategy
undertaken and
requirements
Submission date
Decision date
Amount [k€]
Click here to enter a date.
Click here to enter a date.
Please enter the approximate amount of the possible subsidy in k€
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Chemelot InSciTe Biomedical Application Form
II. KEY DATA AND SUMMARY OF THE PROJECT PROPOSAL
This section gives information relevant for the InSciTe program management to obtain an overview of
the project portfolio of InSciTe’s projects. Max 3 A4.
1. Executive Summary of the proposal
Please enter here an executive summary of max 10 lines
2. Proposed start date
3. Duration of the project [months]
4. Total project costs (direct and indirect) [k€]
Click here to enter a date.
Enter duration in months
Enter project costs in k€
NOTE: Project costs as calculated via the Budget Sheet
5. Research Area:
Choose the Research Area to which your proposal belongs (only one should be selected):
1. Cardiovascular - with a (initial) focus on vessels
2. Orthopedic - with a (initial) focus on cartilage
3. Ophthalmology - with a (initial) focus on drug delivery
6. Key words
Provide up to 5 key words for your
proposal
Please enter here maximal 5 key words
7. Publiekssamenvatting (Dutch)
Please enter here the Dutch summary of max 10 lines;
Deze samenvatting kan gebruikt worden voor communicatie doeleinden, bijvoorbeeld bij het
informeren van een breder publiek o.a. patiëntenverenigingen over de activiteiten van Chemelot
InSciTe o.a. via de Chemelot InSciTe website.
De publiekssamenvatting moet voorzien zijn van een voor een breed publiek pakkende titel. De tekst
moet voor de geïnteresseerde leek begrijpelijk zijn. Dus jargon moet worden omgezet naar normale
Nederlandse termen. En uw verhaal moet zich op hoofdlijnen richten en mag dus wat “kort door de
bocht zijn”.
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Chemelot InSciTe Biomedical Application Form
8. Project HR organization
-
Please provide an HR organizational chart like the scheme below. The number of work
packages is restricted to ≤5; sub-WPs are not allowed.
9. Possibility of Spin off projects
Do you expect that spin-off projects might arise from the current project.
Choose yes/no
Comment
If applicable give a comment of max 5 lines
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Chemelot InSciTe Biomedical Application Form
III. EXTENDED AND DETAILED PROJECT PROPOSAL
In this section a more detailed scientific description of the project is required.
1. Project description
Clinical need and problem definition (address all items separately, max 12,000 char.)
1) Background
2) Current international status of research in this field and the uniqueness of the current proposal
3) Aim, objective(s) and milestones of the project proposal, with a clear description of the expected
clinical and technological breakthrough results including expected timeline towards clinical
implementation
4) Plan of investigation
5) Preliminary results
Please enter here the detailed project description, max 2 A4
1.a.
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Chemelot InSciTe Biomedical Application Form
1. Project description
1.b.
Detailed Working plan (address all items separately, max. 20,000 char.)
1) research per work package
2) milestones and deliverables per work package
3) number and type (e.g. PhD, PD) of researchers per work package
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Chemelot InSciTe Biomedical Application Form
1. Project description
1.c.
Provide a Gantt chart, including timelines and interdependency of the work packages (as
described under 1. Project organization), milestones and deliverable(s) (max. 4,000 char.)
1. Project description
1.d.
Describe potential clinical and technological hurdles that may inhibit successful completion of
the project (max. 4,000 char.)
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Chemelot InSciTe Biomedical Application Form
1. Project description
1.e.
Describe the existing infrastructure at the partners that is necessary to conduct the research in
the project (e.g. equipment, facilities) (max. 4000 char.)
1. Project description
1.f.
If applicable, describe and justify the type and amount of animal and/or clinical studies included in
this proposal (max. 4000 char.)
1. Project description
1.g.
Will the project make use of any proprietary materials that require special agreements with their
supplier/owner (e.g. license)?
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Chemelot InSciTe Biomedical Application Form
Please enter here background information, max 10 lines
1. Project description
1.h.
Describe the use (incl. estimate of Hrs) of the InSciTe biomedical facilities. Clearly indicated which
project members dedicate how much of their research activities in the InSciTe facilities (max. 4,000
char.)
1. Project description
1.i.
Will investment in new equipment for the biomedical facility be necessary for the project
execution? (Note: if this requires considerable effort it has to be part of the overall project plan
e.g. as separate work package)
Choose yes/no
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Chemelot InSciTe Biomedical Application Form
Costs [k€]
please describe
and justify
investment
Enter estimated equipment costs in k€
Enter investment description and justification, max 10 lines
2. Project team
2.a. Describe the specific roles and expertise of the partners in the project
Please enter here the specific roles and expertise of the partners. Max 2 A4
2. Project team
2.b.
Describe the current international position of the project partners with respect to the proposal
(e.g. VSNU research assessment, market position) (max. 4000 char.)
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Chemelot InSciTe Biomedical Application Form
3. Economic/Business value creation
3.a.
1) Describe how the project team will implement the results of this project.
2) Describe the new products, therapies and services that are expected to result from this
project. Estimate their potential economic value. Base your estimate on the type of business
model that is employed, the expected market size, market share, turnover, profit margin, etc.
3) Provide an indication of the additional budget and time needed to develop and market
products resulting from this research project.
4) Describe the key assumptions and uncertainties underlying these projections.
(address all items separately, max. 20,000 char.)
3. Economic/Business value creation
3.b.
Address the benefits for the (Dutch) economy (e.g. by improved position in export, knowledge
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Chemelot InSciTe Biomedical Application Form
generation, contribution to knowledge infrastructure, new spin off companies, new jobs, additional
industrial investments).
(address all items separately, max. 18,000 char.)
3. Economic/Business value creation
3.c.
Sketch the Intellectual Property (IP) landscape. Which opportunities for generating new IP are
envisaged? Do issues with background IP exist?
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Chemelot InSciTe Biomedical Application Form
Please enter here the information on IP, max 20 lines
4. Clinical value creation
4.a.
Describe how the consortium members will translate the results towards clinical
implementation. (max. 4000 char.)
4. Clinical value creation
4.b.
Describe the preclinical and clinical objectives and benefits as well as potential regulatory
hurdles for clinical implementation. List the duration and phasing of preclinical phases.(max.
4000 char.)
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Chemelot InSciTe Biomedical Application Form
4. Clinical value creation
4.c.
Estimate the clinical value of the project results, and the impact on the cost effectiveness of the
(Dutch) healthcare system. The estimate can be based on the interventions that will emerge
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Chemelot InSciTe Biomedical Application Form
from the project, the size(s) of the patient group(s) that are involved, possible savings in the
healthcare sector when implementing the interventions, reduced hospitalization time, and
improved health status and reduced burden of disease. Describe the key assumptions and
uncertainties underlying this projection. (max. 4000 char.)
5. References and attachments
List up to 20 key papers from project partners relevant to the proposal
List up to 5 patents from project partners relevant to the proposal
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Chemelot InSciTe Biomedical Application Form
IV. PROJECT BUDGETING
The estimate of the project costs consists of three parts: Personnel, Materials & services, Usage of
equipment. Moreover, the project team needs to indicate whether investments in the InSciTe
biomedical facilities are needed to execute the project. The overall project costs are calculated from
the costs per Work Package. The information is used to determine if the project budget fulfils the
basic InSciTe budget and funding rules. Details on budgeting will be evaluated based on the
information provided in the Budget sheet, which must be completed and submitted with the proposal.
Please make sure you have read and understood the InSciTe Financial Guidelines before you fill out the
Budget sheet and the application form and please make sure the numbers provided below
correspond fully to the calculated numbers in the Budget sheet.
1. Personnel
Personnel costs: the total amount of personnel costs (including project personnel that works in the
InSciTe facilities) invoiced to InSciTe by Founding Fathers (FF) and by third parties. The average
amount of personnel costs per year must also be calculated. Please specify how the costs are divided
year to year.
1.a. FTE’s
Year
Invoiced to InSciTe by FF
Invoiced to InSciTe by others
Total
Total
1
2
Total
1
2
3
4
3
4
FTE
FTE
FTE
1.b. Euro’s
Year
Invoiced to InSciTe by FF
Invoiced to InSciTe by others
Total
[k€]
[k€]
[k€]
2. Materials & services
Please provide an estimate of materials & services needed for this project, other than regular materials &
supplies which are included in the bench fees. These costs include CMR, animal studies and clinical trials.
2.a. Generic
Requested materials & services
Justification for request
Cost [k€]
Total amount requested [k€]
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Chemelot InSciTe Biomedical Application Form
2.b. Animal studies
Please provide an estimate of animal studies needed for this project. Specify amount of animals and
species. Include these costs in the total amount of requested materials & services.
Requested animal study
Justification for
Cost [k€]
DEC approval [y/n]
request
2c. Clinical studies
Please provide an estimate of clinical trials for this project. Indicate expected amount of individuals
needed. Include these costs in the total amount of requested materials & services.
Requested clinical trials
Justification for
Cost [k€]
MEC approval [y/n]
request
3. Usage of equipment
Please provide an estimate of the use of equipment needed for this project, in so far these costs
substantially exceed the fees and overhead (which are meant to cover for existing infrastructure). These
costs include third party costs. Costs can be charged on the basis of integral cost rates, excluding profit
margins, which are used within your organizations. Rates may be subject to auditing by an (InSciTe)
accountant.
Requested usage of equipment
Justification for
Time [Hrs]
Cost [k€]
request
4. Investments needed for the InSciTe biomedical facility
Please indicate whether execution of the project is dependent on investments in (specialized)
dedicated equipment.
Note. The personnel needed to operate this equipment should be part of the (project) budget.
Requested investment
Justification for request
Cost [k€]
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Chemelot InSciTe Biomedical Application Form
5. Project partner contributions
Please indicate the contributions from the participants (Founding Fathers and/or third parties and/or
subsidies). Specify the exact contribution each project partner offers.
Founding Father:
Name
Total contribution[k€]
total
Third Parties:
Name
Total contribution[k€]
total
Subsidies:
Name
Total contribution[k€]
total
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Chemelot InSciTe Biomedical Application Form
V. Signing
Signature Project Leader
Date
Place
Signature
Name and position
Signature Participants’ Representative
Date
Place
Signature
Name and position
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