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 Category Hispanic or Latino Not Hispanic or Latino Racial Category American Indian/ Alaska Native Black or African American Native Hawaiian or Other Pacific Islander White CorrespondencePlease use the following information for all correspondence regarding this grant applicationPrincipal Investigator*Principal investigator must be an NASBS Member. First Last Degree(s) Institution* Department* Professional Title* Mailing 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email* Grant InformationType of Grant*Clinical 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. Clinical Research Basic Science/Translational Research Project Title*Total Amount Requested*Start Date for Project* MM slash DD slash YYYY End Date for Project* MM slash DD slash YYYY Co-InvestigatorsNameInstitutionTitle Please use the + icon to add new rows for new co-investigatorsCover Letter*Please de-identify your cover letter to the extent possible. Max. file size: 512 MB.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 Please de-identify application materials to the extent possible.Max. file size: 512 MB.Curriculum Vitae for PI*Max. file size: 512 MB.Curriculum Vitae for any Co-PI Drop files here or Select files Max. file size: 512 MB. Disclosures/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.NameThis field is for validation purposes and should be left unchanged.
