Form 1
FFC Grant Application 2010

General Information   (please fit spaces and add sheets if necessary)

Project Title:______________________________________________________________________
________________________________________________________________________________
Running Title (state with few appropriate keywords the contents of the research): ___________________________________________________________________________
No. Centres Involved ____ No. Researchers involved (including partners and internal/external collaborators) _____    Project Duration (yrs) ______
Type of Application: New FFC Applicant ___     Old FFC Applicant ___
                                    New FFC Application ___   Prosecution of previous FFC Application ___
Research Area (see priority areas in the FFC Call for application):___________________________
Research Type (prevalent matter):___________________________________________________
Human subjects involved: Yes ___  No ___     Animal models involved: Yes ___  No ___

Applicant (Principal Investigator or Coordinator) – Personal data
Name_______________________________ Surname_____________________________________ 
Fiscal Code_____________________ Birth date ___/___/_____ Degree______________________
Annual effort in the project % ____
Address: (Department/University/Hospital/Institution/Lab)_______________________________
Street _______________________________ Zip Code _________ City______________________ Prov._______ Country_______________________________
Phone _____________________Fax___________________ E-mail_________________________                                  
Internal Collaborators: 
1. Name______________________________ Surname _______________________________ 
   Degree______________________________ Role __________________________________
2. Name______________________________ Surname _______________________________ 
   Degree_____________________________ Role __________________________________
Add others if necessary. Collaborators for whom a salary is requested must be indicated

Partner 1 – Personal data
Name________________________________ Surname____________________________________ 
Fiscal Code______________________ Birth date ___/___/_____ Degree_____________________
Annual effort in the project % ____
Address: (Department/University/Hospital/Institution/Lab)________________________________
Street _____________________________ Zip Code _________ City_________________________ Prov._________ Country____________________________________
Phone _____________________Fax___________________ E-mail__________________________                                  
Internal Collaborators: 
1. Name______________________________ Surname _______________________________ 
   Degree_____________________________  Role __________________________________
2. Name______________________________ Surname _______________________________ 
   Degree_____________________________  Role __________________________________
Add others if necessary. Collaborators for whom a salary is requested must be indicated

Partner 2 – Personal data
Name_______________________________ Surname____________________________________ 
Fiscal Code_____________________ Birth date ___/___/_____ Degree______________________
Annual effort in the project % ____
Address: (Department/University/Hospital/Institution/Lab)________________________________
Street ___________________________ Zip Code _________ City______________________ Prov._______ Country___________________________________
Phone _____________________Fax___________________ E-mail__________________________                                  
Internal Collaborators: 
1. Name______________________________ Surname _______________________________ 
   Degree_____________________________  Role __________________________________
2. Name______________________________ Surname _______________________________ 
   Degree_____________________________  Role __________________________________
Add others if necessary. Collaborators for whom a salary is requested must be indicated

Partner 3, 4 ………..
Add further Partners and numbered sheets if necessary

Form 2

FFC Grant Application 2010

Curriculum Vitae  (Add numbered sheets if necessary)

P.I. / Coordinator
Education and Training (max 3500 chars)

Employment and Research Experience (max 3500 chars)

Personal bibliography (list of references peer-reviewed, last five years)

______________________________________________________________________________________________
Partner 1
Education and Training (max 3500 chars)

Employment and Research Experience (max 3500 chars)

Personal bibliography (list of references peer-reviewed, last five years)
___________________________________________________________________________________________
Partner 2
Education and Training (max 3500 chars)

Employment and Research Experience (max 3500 chars)

Personal bibliography (list of references peer-reviewed, last five years)

Add further sheets if necessary

Form 3

FFC Grant Application 2010

Project Overview – (Abstract)  (max 3000 chars)
Background/Rationale

Objectives	

Preliminary results (personal)

Project description (experimental plan, methods, timing)

Anticipated output

Relevance to Italian CF Foundation mission

Form 4

FFC Grant Application 2010
Research Plan: Background, Specific Aims and Rationale
Background (max 5000 chars)

Specific Aims and Rationale   (max 5000 chars)

Add sheets if necessary

Form 5

FFC Grant Application 2010

Research Plan: Preliminary Results (max 8000 chars, please insert into the text images or graphs as JPG files)

Add numbered sheets if necessary

Form 6

FFC Grant Application 2010

Research Plan: Experimental Plan and Methods    (max 15.000 chars, add sheets)

Experimental Plan

Material and Methods
If human subjects or animals will be involved in the study, you should estimate the number of subjects needed in your experimental design also with regard to the effect which should be achieved for given levels of statistical significance and power. 

Sequence/Timing of the Project

___________________________________________________________________
If Clinical Project
Clinical protocols
Study design, detailed study population, clinical procedures, study medications/drugs (if applicable), safety, data management and statistical analysis, timetable. State whether material or data will be obtained specifically for research purposes or whether use will be made of existing specimens, records or data. State also whether the clinical procedures/interventions will be specifically applied for research purposes or for usual care plans. The Informed consent form and the information sheet must be attached (see FFC Announcement, item 5). The Clinical project must be completed with Ethical Committee’s Authorisation in accordance with the laws of the Italian Ministero della Salute.

______________________________________________________________________________________________

Cited Bibliography

Add numbered sheets
Form 7

FFC Grant Application 2010

Host Institution/s: Facilities
P.I. / Coordinator
Position Title _________________________________________  Permanent Position  Yes _____  No _____
Main Research Fields______________________________________________________________________
Laboratory (or clinical dept.) Name _________________________ Chief ____________________________
No. Staff Members ____
Facilities
Lab space ___________________________ Clinical resources _____________________________________
Computer Equipment______________________________________________________________________
Major Equipment ________________________________________________________________________
Core Facilities and Services ________________________________________________________________
______________________________________________________________________________________
Other _________________________________________________________________________________
______________________________________________________________________________________

Partner 1
Position Title _________________________________________  Permanent Position  Yes _____  No _____
Main Research Fields_____________________________________________________________________
Laboratory (or clinical dept.) Name __________________________ Chief __________________________
No. Staff Members _____
Facilities
Lab space __________________________ Clinical resources _____________________________________
Computer Equipment______________________________________________________________________
Major Equipment ________________________________________________________________________
Core Facilities and Services _________________________________________________________________
_______________________________________________________________________________________
Other __________________________________________________________________________________
_______________________________________________________________________________________
Partner 2, 3, …….
As above, add sheets
Form 8

FFC Grant Application 2010
Outside Collaborations/Services
Collaborations must be supported by collaboration letters.

Collaboration 1
Name                                                                           
Institution/Laboratory
Contribution to the project:

Collaboration 2
Name                                                                           
Institution/Laboratory
Contribution to the project:

Other

Form 9

FFC Grant Application 2010
Budget   The budget description must be accurate in all its parts and every item must be justified to the needs of the project. Any omission, generic description, or miscalculation may lead to the project’s rejection

	Description/Justification	1st year	2nd year	3rd year	TOTAL	
Equipment
(very limited)						
Material,
Supplies,
Services						
Salaries,
Wages						
Travels and Publications
(max 4% of the total amount required)						
Outside
Collaborations/
Services						
TOTAL						

In case of Multicentre project you must also specify the budget per each Partner in a unique table as follow:

	Description/Justification     	1st year	2nd year 	3rd year	TOTAL	
Equipment

	Coordinator
Partner 1
Partner 2	

	

	
Material,
Supplies,
Services

	Coordinator
Partner 1
Partner 2

	

	

Etc………

Other Financial Supports (if available)
Current ___    Pending ___     Period: from__________ to ___________
Amount:
Project Title:
Brief Description:
Granting Agency:
Appropriate document must be attached
Form 10

FFC Grant Application 2010

For Multicentre Projects only 
Role and Contribution of Partner(s) in the project     
Coordination and Management    

Partner 1
Name                                                                                               Annual Effort % ___
Specific Role and Contribution:

Partner 2
Name                                                                                                Annual Effort % ___
Specific Role and Contribution:

Partner 3, 4, ……..    Add sheets

Coordination and Management
Monitoring activities of the Partners:

Facilitating communication:

Promoting exchange of ideas and methodological approaches:

Stimulating analysis and integration of results:

Form 11

FFC Grant Application 2010
                    
Lay Summary
Project Title (in Italian)  

Keywords (in Italian)

Project Summary (in Italian) max 2500 chars

Project Summary (in English)   max 2500 chars

Keywords (English)

Form 12

FFC Grant Application 2010

List of documents included (basic and additional)  See FFC Call for Application, items 3, 4, 5 and all the other forms.

						

Pro forma declaration A

PROJECT TITLE: “................................................................................................................”

(P.I. or Co-ordinator: ..........................................)

Declaration of consent for processing personal data

Whereas, the processing of my personal data shall be performed for the following purposes:

•	Administrative management of the dossier;
•	Evaluation of the value of the research projects with transmission of the data to the Italian and non Italian referees/evaluators;
•	Activities ancillary and/or pursuant to the above

•	I give my consent
•	I deny my consent

The communication of personal data for these purposes is not compulsory, although refusal to do so, owing to the peculiarity of the relationship between the data and the aim for which they are requested, may mean that the candidate will not be able to be considered for selection.

Whereas, for the purpose of carrying on its activity the Italian Cystic Fibrosis Research Foundation – onlus, shall communicate and/or make public the personal data of the researchers to whom funds have been allocated (indicating their affiliations) as their research projects have been deemed worthy of funding

•	I give my consent
•	I deny my consent

Name ____________________________

Signature_________________________

Date ____________________________

Pro forma declaration B

PROJECT TITLE: “................................................................................................................”

(P.I. or Co-ordinator: ..........................................................)

DECLARATION OF ACCEPTANCE OF COLLABORATION

I certify that I will collaborate in the above mentioned project submitted to the Fondazione per la Ricerca sulla Fibrosi Cistica – onlus for the FFC Grant application 2010 as ......................... (role in the project)

Name ________________________________

Signature______________________________

Date__________________

Pro forma declaration C

PROJECT TITLE: “................................................................................................................”

(P.I. or Co-ordinator: ..........................................................)

DECLARATION OF ACCEPTANCE OF PARTNERSHIP

I, (name, personal data, address, telephone and fax number, e-mail and fiscal code)

DECLARE

that I will collaborate in the above mentioned project submitted to the Fondazione per la Ricerca sulla Fibrosi Cistica – onlus for the FFC Grant application 2010 as Partner (number in the Project)

Name ________________________________

Signature______________________________

Date__________________

Pro forma declaration D

PROJECT TITLE: “................................................................................................................”

(P.I. or Co-ordinator: ..........................................................)

Declaration of accordance with the instructions of the D. Lgs. 27-11-1992 n. 116 on the protection of animals utilized for experimental aims.

I declare that any procedures planned in this project with reference to the use of animal models will follow the instructions included in the D. Lgs. 27-11-1992 n. 116.

Type of animals: _________________________________________________________

Estimated number of animals: _______________________________________________

Institute/Laboratory at which animals will be bred and treated: ______________________

_______________________________________________________________________

P.I. (or Co-ordinator) Signature ______________________________________________

Name of the responsible of the animal treatment ________________________________

Signature _________________________________

Date ____________________________________

Pro forma declaration E

PROJECT TITLE: “................................................................................................................”

(P.I. or Co-ordinator: ..........................................................)

I declare that any procedures planned in this project with reference to clinical trials on human subjects will follow the instructions of Good Clinical Practice [Italian Decree July 15, 2007; D.Lgs 211/2003 (adoption of the European direction 2001/20/CE); D.Lgs 200/2007 (adoption of the European direction 2005/28/CE)].

P.I. (or Co-ordinator) Signature ______________________________________________

Signature _________________________________

Date ____________________________________

Pro forma declaration F

PROJECT TITLE: “................................................................................................................”

(P.I. or Co-ordinator: ..........................................................)

Authorization of the Ethical Committee of the Research Institute for animal experiments

I declare that the authorization of the Ethical Committee of the Research Institute (Name) for the animal experiments that will be performed in this project will be provided not later than June 15, 2010.

Name of the responsible of the animal treatment ________________________________

Signature _________________________________

Date ____________________________________

P.I. (or Co-ordinator) Signature ______________________________________________