ACDS Outcomes Research Award Application

Thank you for your interest in applying for the ACDS Outcomes 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.

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Primary Investigator Information

First Name*:

Middle Name:

Last Name*:

Street/Mailing Address:

Street/Mailing Address (line 2):

City:

State/Province:

ZIP/Postal Code:

Country:

Phone* (include extension):

Email*:

Co-Investigator Information

First Name:

Middle Name:

Last Name:

Street/Mailing Address:

Street/Mailing Address (line 2):

City:

State/Province:

ZIP/Postal Code:

Country:

Phone (include extension):

Email:

Fiscal Officer Information

Fiscal Officer to whom payment should be directed. Note: Without complete and accurate information for this section, checks cannot be mailed.

Full Name:

Street/Mailing Address:

Street/Mailing Address (line 2):

City:

State/Province:

ZIP/Postal Code:

Country:

Institution/Department Information

Name of Institution:

Sponsoring Department:

Head of Sponsoring Department:

Department Phone:

Department Street/Mailing Address:

Department Street/Mailing Address (line 2):

City:

State/Province:

ZIP/Postal Code:

Country:

Dean or Administrative Official Information

Full Name:

Title:

Phone:

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Country:

Proposal

Please upload your submission below.

Please include a page listing the Fiscal Officer, the Project Director (or Applicant), Department Head and the Dean/Administrative Official along with their signatures agreeing to the statement below.

Grantee shall indemnify, defend and hold harmless American Contact Dermatitis Society (ACDS) and its officers, directors, members, agents and volunteers from and against all claims, damages, losses and expenses (including reasonable attorneys' fees) arising out of or in connection with the actions or inactions of Grantee, Principal Investigator, and Co-Investigator in connection with the Study, including, without limitation, any claims or actions based upon or arising out of damage or injury (including death) to persons or property, or claims for payment or non-payment, caused by or sustained in connection with the performance of the Study.

[ ] Agree
[ ] Do not agree

Proposal file (Word or PDF)*:

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 report and financial report to the ACDS within 90 days of the termination of my research program.

ACDS Outcomes Research Award Application

Primary Investigator Information

Co-Investigator Information

Fiscal Officer Information

Institution/Department Information

Dean or Administrative Official Information

Proposal

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