2024 Pennsylvania Allergy & Asthma Association Research Grant Application

2024 Pennsylvania Allergy & Asthma Association Research Grant Application
For PAERF Use Only - Log No.
Date*

MonthDayYear
Date
Applicant's Name*

First NameLast Name
Applicant's Phone Number*
Please enter a valid phone number.
Applicant’s Email*
example@example.com
FIT Enrolled in PA Accredited Training Program?

YesNo
*If Fellow, Complete Training Program Director's Name and e-mail below. Program Director will receive this to sign off on after you complete this form.
Program Director's Name

First NameLast Name
Program Director's Email
example@example.com
Institution Name
Institution Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Institution Phone
Institution Fax
Name of Administrative Official to be Notified in the Event of Funding

First NameLast Name
Administrative Official's Email
example@example.com
Administrative Official's Phone Number
Please enter a valid phone number.
Administrative Official's Fax
Title of Project*
Total Amount Requested (USD)*
Proposed Start Date*

MonthDayYear
Date
Duration*
Approval Information (Check each of the following):

Does this Project Involve the Use of: *

	Yes	No
1a. Human subjects?
2a. Vertebrate animals?
3a. Radioactive materials/radiation-producing equipment?
4a. Investigational new drugs or new devices?
5a. Potentially infectious agents, including human blood or tissue
6a. Carcinogens?
7a. In vitro formation of recombinant DNA?

Approval Attached? (Complete if you selected "yes" in section above)

	YES	NO	Protocol File Date	Date Approved	Protocol Number
1b.
2b.

If applicable, human subject and/or animal approval are not required at the time of application. However, in the event the grant is funded, applicable approvals must be forwarded to PAERF before any funds are released.
Application Attachments
To complete your application, for each section below, please attached the requested files. Please note, you will NOT have an opportunity to upload the documents later. :

Section 1: (Application Forms)

1. Budget Page - Please describe, on a half-page or less, how the funds will be spent. Please note no indirect costs will be covered by this grant.
File Upload*

Cancelof
Section 2: (Research Plan)

1. In no more than two pages, please describe your specific aims, the significance, the experimental design and methods, and the anticipated outcomes.

2. Bibliography (one to two pages, not includied in the total).
File Upload*

Cancelof
Section 3: (Applicant and Mentor Information)

1. Please provide a biographical sketch of the applicant.

2. Please provide a biographical sketch of the applicant's mentor

3. Please submit a one page letter of support from the applicant's mentor.
File Upload*

Cancelof
Section 4: (Signatures: Applicant, Training Program Director and Administrative Official)

1. Applicant - Sign Applicant Signature block below.

2. Training Program Director - Please forward the link below to your training program director and ask that they complete and submit the certification form.

https://form.jotform.com/230785513997066

3. Administrative Official (if applicable) - Please forward the link below to your administrative official and ask that they complete and submit the certification form.

https://form.jotform.com/230785942452159
Applicant Signature
FIT/MEMBER APPLICANT: I certify that the information provided is accurate and complete as of this date. I agree to accept responsibility for scientific and technical conduct of this project and for provision of required technical reports if a grant or contract is awarded as a result of this application. *

Clear
Please print your name*
Date*

MonthDayYear
Date
Should be Empty:

2024 Pennsylvania Allergy & Asthma Association Research Grant Application

Applicant Signature