Research Grant Application Research Grant Application The NASBS seeks to promote meritorious proposals from a diverse group of researchers. To help NASBS promote diversity in the research grants, we are asking the following questions about gender, race, and ethnic groups. These are optional, and applicants are not obligated to answer. Gender:Ethnic CategoryHispanic or LatinoNot Hispanic or LatinoRacial CategoryAmerican Indian/ Alaska NativeBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteCorrespondencePlease use the following information for all correspondence regarding this grant applicationPrincipal Investigator*Principal investigator must be an NASBS Member. First Middle Last Suffix InstitutionDepartmentProfessional TitleMailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email* Grant InformationType of Grant*Clinical ResearchBasic Science/ Translational ResearchClinical Research: Investigations that are centered on clinical care seeking answers to novel questions through well designed prospective or retrospective methods. Basic Science/ Translational Research: Investigations targeting the underpinnings of relevant anatomic and pathologic states or seeking to take basic science concepts and apply them to skull base diseases and disorders. Project Title*Total Amount Requested*Start Date for Project* Date Format: MM slash DD slash YYYY End Date for Project* Date Format: MM slash DD slash YYYY Co-InvestigatorsNameInstitutionTitle Please use the + icon to add new rows for new co-investigatorsCover Letter*Application*Your application should be written in size 12 font with 1' margins and should include the following: 1. Summary Abstract of Proposal Research Study (500 words maximum) 2. Research Plan with the following sections: Specific Aims Background/Significance Methodology Data analysis plan with sample size justification (if applicable) IRB/ IUCACV approval number or timeline for obtaining approval (as applicable) 3. Budget Jusification (please note that grants can not be used for salary support or indirect costs) Provide an in-line item format, each expenditure item, and the cost associated 4. Curriculum Vitae for PI and any Co-PIDisclosures/Conflict of InterestPlease disclose any employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications, research/travel grants, etc. for the Principal Investigator and each of the co-principal investigators. PI Disclosure*Anything to Disclose (Y/N)If Y, list companies, roles, what was received Please use the + icon to add new rows for new company disclosures. If you have nothing to disclose, enter N on the first line.Co-PI DisclosuresCo-PI NameAnything to Disclose (Y/N)If Y, list companies, roles, what was received Please use the + icon to add new rows for new Co-PIs and/or new company disclosures. If all Co-PI's have nothing to disclose, create new rows for each Co-PI and enter N under Anything to Disclose.UntitledCommentsThis field is for validation purposes and should be left unchanged.
