ACDS Clinical Research Award Application

Thank you for your interest in applying for the ACDS Clinical Research Grant. Please complete the below information and submit by the designated deadline to be considered for the grant. Please contact info@contactderm.org or call 414-918-9805 with any questions you might have.

* = required field

Applicant's Contact Information

First Name*:

Last Name*:

Applicant's Title* (Medical Student, Resident, Fellow, etc.):

Street/Mailing Address:

Street/Mailing Address (line 2):

City:

State/Province:

ZIP/Postal Code:

Country:

Phone* (include extension):

Fax:

Email*:

Citizenship*:

Applicant's Institutional Appointments (include years)*:

Research to be conducted at what institution?*:

Research Supervisor's Name and Title*:

Supervisor's Email*:

Title of Proposal*:

Proposed Budget

Provide a detailed budget as a separate attachment. The funding for this fellowship is not to be used to provide funding for indirect institutional costs (including salary for investigator or supervisor, travel to meetings, or overhead costs, at universities. Equipment such as personal computers will not be funded. Personnel costs for data analysis, for example, are acceptable. Travel may be approved under special circumstances.

Budget Details to include:

Personnel costs
Equipment
Supplies (expendable)
Other
Total Amount in $ US

Amount requested*:

Budget as PDF or MS Word file*:

Proposal Instructions

Description: Describe your proposal in sufficient detail for adequate evaluation by the ACDS Clinical Research Studies Committee. Make every effort to be succinct and use figures or tables to summarize your plans. Items 1-6 below should not exceed ten pages. Do not submit a copy of any application prepared for another grant.

A suggested proposal format is listed below:

Specific Aims: What do you intend to accomplish? What hypothesis is to be tested?
Significance: Why is the research important? Evaluate existing knowledge in the field and specifically identify the possible contributions that your investigation may make.
Preliminary Studies: What has already been done in this field?
Organizational Structure: Please describe in detail how your supporting organization is structured to support your research. Please include a supporting letter from your sponsor/advisor describing the nature of the organizational support (including that of your advisor) to your project.
Experimental Design: How are you going to accomplish the research? Describe the experimental design, the procedures to be used, and the manner in which the data will be analyzed. Do not include established laboratory procedures.
Literature Cited.

Proposal as MS Word or PDF file.*:

IRB Approval or Status Report*:

Letter of support from your research supervisor*:

Curriculum Vitae – include a brief biographical sketch and a recent, relevant bibliography.*:

Other supplemental material:

I certify that the statements in this application are true to the best of my knowledge. I agree that the award funds will be used only for the purpose reflected in my application. Any unused funds will be returned to the ACDS. I hereby agree to provide a written progress and financial report to the ACDS within 90 days of the termination of my research program.

ACDS Clinical Research Award Application

Applicant's Contact Information

Proposed Budget

Proposal Instructions

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