Project Title

Amount Requested

Proposed start date and proposed completion date

Is this a re-submission?

Other funding:

• I have submitted this proposal for funding from (NIH, OREF, other)
• This proposal has received funding from
• I have not submitted this proposal for funding from any other organization
• Related projects have received funding (List title/s and funding source/s below)

Principle Investigator name and contact information

Membership category

SRS Member(s) Involved

Institution

Signing Official

Research Team (In case of multicenter project: Specify lead investigator for each participating center)

Location where research is to be performed (In case of multicenter project: Specify participating centers, and what they will contribute)

The Problem – identify the problem to be studied

Hypothesis and Goals

Study Proposal/Methods – Provide a description of the methodology to test hypothesis/hypotheses, and anticipated results. If applicable, provide a brief anticipated sample size calculation. If sample size is not applicable, please provide rationale.

Previous Work in this Area

Budget/Timeline – Briefly describe how these aims can be accomplished with the budget and timeline provided for this grant.  If the scope of the application is beyond the budgetary and timeline limitations, please describe if/how outside funding sources or research programs will make up for the shortfall.  Please note: travel expenses and indirect costs are not allowed. 

Feasibility – Briefly describe the experience/collaborative history of the research team and available resources and how these will ensure the likelihood of success in carrying out the proposed research. 

Keywords (up to 5)

Lay Summary

Conflict of Interest Disclosure -

• Instructions - Conflict of Interest Disclosure Instructions.pdf
• Disclosure Form – Conflict of Interest Disclosure Form.pdf
• Please upload all investigator conflict of interest forms in one document.

Upload Letters of Support (Optional)

Project Title

Resubmission?  If so, how was it revised?

Total Amount Requested

Project Start Date and Project End Date

Supplemental Information

• Work currently in progress?
• Applied elsewhere for support?
• Does this project utilize a database from a study group?  If yes, explain your relationship to this study group and clarify how this is an otherwise unfunded project.
• Please disclose any industry support for and/or participation in this or related projects.

Principal Investigator Information

Identify if PI or Co-Investigator is SRS Member

Institution

Facilities available

Financial Officer Information

Marketing Contact Information

Research Team- In case of multicenter project: Specify lead investigator for each participating center

Collaborating Investigator(s) Information

• Name
• Institution
• E-mail

Project location/s- In case of multicenter project: Specify participating centers, and what they will contribute

Lay Summary

Abstract (not to exceed 200 words)

Budget – Summary and Justification (all personnel costs should be explained)

• 1 Year    2 Year   3 Year

Publications/References

Biographical Sketches (Max 5 pages per contributor. Must be combined into one document for upload)

• For Principal Investigator and any Collaborating Investigators, including date of birth, education (BA, BS, MS, PhD, MD) postgraduate training (internship, residency, fellowship), hospital and academic appointments, thesis titles and supervisors, and any relevant publications.
• Template

Upload Research Plan - Limited to 10 pages maximum. 

• Should answer at minimum:
  • Why is the work important?
  • What do you plan to do?
  • What has already been done?
  • How long will it take you to do the work?
• Should be further organized as follows:
  • Specific Aims
  • Significance
  • Materials and Methods
  • Supporting Data (References, appendices, and post-plan images will not count against your page limit.)

Project Title

New submission or Re-submission, if re-submission, how was it revised?

Amount Requested

Proposed Project Period (Start and Completion date)

Applied elsewhere for support?

Disclose any industry support for an/or participation in this or related projects

Received any other funding for this project? If so, from where and how much?

PI Name and contact information

Membership category

SRS Member(s) Involved

Institution

Research Team

Purpose of the project/research question if research project

Impact that your project will have on the SRS mission, your career, or your specialty

Primary outcome measure of success

List up to 3 Keywords

Lay Summary

Abstract

Micro Grant Classification

• Research
• Education
• Observership/Mission
• Advocacy
• Quality/Safety Improvement
• Other

Budget Details 1 Year

IRB Disclosure

Regulatory Disclosure: If a device/drug requiring FDA, EU-MDR, or your local/regional specific regulatory body’s approval is identified as an important component of the study, please indicate the status of those devices/drugs.

• FDA, EU-MDR, or local/regional specific regulatory clearance is NOT APPLICABLE
• The FDA, EU-MDR, or local/regional specific regulatory body has cleared all pharmaceuticals and/or medical devices for the use described in this study
• The FDA, EU-MDR, or local/regional specific regulatory body has not cleared the following pharmaceuticals and/or medical devices for the use described in this study. The following pharmaceuticals and/or medical devices are being discussed for an off-label use

Publications/References

Attach Applicant Biosketch/CV Template (Max 5 pages per PI)

Attach Key Personnel Biosketch/es Template (Max 5 pages per contributor. Must be combined into one document for upload)

Project Title

Amount Requested

Location where research is to be performed

Proposed start date and proposed completion date

Is this a re-submission?

Other funding:

• I have submitted this proposal for funding from (NIH, OREF, other)
• This proposal has received funding from
• I have not submitted this proposal for funding from any other organization
• Related projects have received funding (List title/s and funding source/s below)

Principle Investigator name and contact information

Membership category

SRS Member(s) Involved

Institution

Research Team

Problem/Need  – Identify the problem to be studied and the unmet need(s) to be addressed.

Significance – Provide the most up-to-date estimate of epidemiology, morbidity, mortality and cost of the problem, and how this project relates to the SRS mission

Hypothesis and Goals

Study Proposal/Methods – Provide a description of the methodology to test hypothesis/hypotheses, and anticipated results. If applicable, provide a brief anticipated sample size calculation. If sample size is not applicable, please provide rationale.

Previous Work in this Area

Budget/Timeline – Briefly describe how these aims can be accomplished with the budget and timeline provided for this grant.  If the scope of the application is beyond the budgetary and timeline limitations, please describe if/how outside funding sources or research programs will make up for the shortfall.  Please note: travel expenses and indirect costs are not allowed. 

Feasibility – Briefly describe the experience/collaborative history of the research team and available resources and how these will ensure the likelihood of success in carrying out the proposed research. 

Keywords (up to 5)

SRS Research Agenda: Does this proposal align with any SRS Research Agenda item/s? If so, please list.

Lay Summary

Regulatory Disclosure: If a device/drug requiring FDA, EU-MDR, or your local/regional specific regulatory body’s approval is identified as an important component of the study, please indicate the status of those devices/drugs.

• FDA, EU-MDR, or local/regional specific regulatory clearance is NOT APPLICABLE
• The FDA, EU-MDR, or local/regional specific regulatory body has cleared all pharmaceuticals and/or medical devices for the use described in this study
• The FDA, EU-MDR, or local/regional specific regulatory body has not cleared the following pharmaceuticals and/or medical devices for the use described in this study. The following pharmaceuticals and/or medical devices are being discussed for an off-label use

Conflict of Interest Disclosure -

• Instructions - Conflict of Interest Disclosure Instructions.pdf
• Disclosure Form – Conflict of Interest Disclosure Form.pdf
• Please upload all investigator conflict of interest forms in one document.

Project Title

Resubmission?  If so, how was it revised?

Total Amount Requested

Project Start Date and Project End Date

Supplemental Information

• Work currently in progress?
• Applied elsewhere for support?
• If requesting more than $X per year, are you able to secure additional moneys if SRS only approves partial funding?
• Does this project utilize a database from a study group?  If yes, explain your relationship to this study group and clarify how this is an otherwise unfunded project.
• Please disclose any industry support for and/or participation in this or related projects.

SRS Research Agenda: Does this proposal align with any SRS Research Agenda item/s? If so, please list.

Principal Investigator Information

Identify if PI or Co-Investigator is SRS Member

Institution Where Work Will Be Done

Facilities available

Financial Officer Information

Marketing Contact Information

Research Team

Collaborating Investigator(s) Information

• Name
• Institution
• E-mail

Lay Summary

Abstract (not to exceed 200 words)

Budget – Summary and Justification (all personnel costs should be explained)

• 1 Year    2 Year

IRB Disclosure

Regulatory Disclosure: If a device/drug requiring FDA, EU-MDR, or your local/regional specific regulatory body’s approval is identified as an important component of the study, please indicate the status of those devices/drugs.

• FDA, EU-MDR, or local/regional specific regulatory clearance is NOT APPLICABLE
• The FDA, EU-MDR, or local/regional specific regulatory body has cleared all pharmaceuticals and/or medical devices for the use described in this study
• The FDA, EU-MDR, or local/regional specific regulatory body has not cleared the following pharmaceuticals and/or medical devices for the use described in this study. The following pharmaceuticals and/or medical devices are being discussed for an off-label use

Biographical Sketches (Max 5 pages per contributor. Must be combined into one document for upload)

• For Principal Investigator and any Collaborating Investigators, including date of birth, education (BA, BS, MS, PhD, MD) postgraduate training (internship, residency, fellowship), hospital and academic appointments, thesis titles and supervisors, and any relevant publications.
• Template

Upload Research Plan - Limited to 10 pages maximum. 

• Should answer at minimum:
  • Why is the work important?
  • What do you plan to do?
  • What has already been done?
  • How long will it take you to do the work?
• Should be further organized as follows:
  • Specific Aims
  • Significance
  • Materials and Methods
  • Supporting Data (References, appendices, and post-plan images will not count against your page limit.)

• Biosketch Template (Max 5 pages per contributor. Must be combined into one document for upload)
• Conflict of Interest Disclosure and instructions (Please upload all investigator conflict of interest forms in one document)