Expression of Interest Form

This form is for researchers submitting an EOI. Please ensure that you have read our ‘applying for support’ information that includes information about our mission, strategy, exclusions, eligibility criteria and process before proceeding.

Step 1 of 3

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This field is for validation purposes and should be left unchanged.

Contact Information

Chief Investigator(Required)

Prefix First Initial Last

Organisation(Required)

Position(Required)

Department or Institute(Required)

ORCID number

How long have you been employed by this organisation (years)(Required)

Please enter a number from 1 to 40.

What is your position's renewal date(Required)

DD slash MM slash YYYY

Your Email Address(Required)

Enter Email Confirm Email

Your Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region Postcode Country

Organisations website

Please paste your full URL here.

Administering Institution

Registered name(Required)

ABN(Required)

Contact Person(Required)

First Last

Phone(Required)

Email(Required)

Postal address(Required)

Street Address Address Line 2 City State / Province / Region Post code Country

DGR Status

DGR1

DGR2

Proposal Overview

Project Name(Required)

Grant round(Required)

Alzheimer’s disease grants are open to portfolios 1,2 and 3 applications. All other grant rounds are open to portfolios 2 & 3 only.

Primary Indication(Required)

Select a primary disease or condition

Requested amount(Required)

How much is this grant requesting

Total program budget(Required)

Total of all funding going for the program

Percentage of Total Budget

Grants: Research Portfolio(Required)

Note: Portfolio 1 is only open in our Alzheimer’s disease grant round

Innovation(Required)

What is the primary regulated product

Starting Date(Required)

DD slash MM slash YYYY

Completion Date(Required)

DD slash MM slash YYYY

Multi year(Required)

Yes

Duration (years)(Required)

Overview of the project(Required)

Outline who may benefit from this innovation. Why is there a need and what alternatives exist or are in development.

Strategic fit(Required)

Briefly describe the innovation and how it aligns with the Foundation’s mission and strategy.

Portfolio alignment(Required)

Briefly outline why this EOI aligns with the selected portfolio. Highlight the need for funding, co-investigators and groups performing the research.

Research

Non-confidential lay descriptions requested throughout

Aims of the research (lay descriptions)(Required)

Outline the aims of the research

Does the research utilise quality systems?

ISO

GLP

GMP

Milestones(Required)

Please indicate your key milestones, completion dates and associated budget. (Max=10)

Milestone

Completion Dates

Budget

Your innovation(Required)

Outline evidence to support the potential of your innovation and any competitive advantage. You may attach a single page PDF of data and tables at the end of the form.

Translational pathway(Required)

Briefly describe the likely translational pathway.

Advancing the innovation(Required)

Briefly describe the research this grant will support and how it relates to advancing the innovation. Refer to the current stage, known research outcomes and the importance of the study to be undertaken in securing next-step partners.

You may upload a single page PDF of data and charts to support your EOI at the end of this form before submitting. Save and continue does not save uploaded forms.

Translation experience(Required)

Briefly outline your experience in innovation, commercialisation and collaborations. What support is available through your institution for this project.

Current and Past Funding

Sources of funds(Required)

Please include all funds associated with this innovation. (Max=10)

Year from

Year to

Source (eg NHMRC)

Amount

Intellectual Property

Is their IP arising from this research(Required)

Yes

Has an invention disclosure form been filed with your institution(Required)

Yes

Intellectual Property(Required)

Please identify all owners, inventors and rights holders for the innovations IP and outline how the IP is being managed.

Patent filings(Required)

Please list any patent filings associated with this innovation. (Max=10)

Date

Filing number

Stage (eg PCT)

Certifications and Approvals

Ethical and Hazardous Implications of the Proposed Research(Required)

Does the research involve any of the listed activities. a) Experimentation on human subjects b) Experimentation on animals (c) The use of Potent CARCINOGENS or TERATOGENS (d) The use of IONISING RADIATION (e) Non-exempt RECOMBINANT DNA work

Yes

Other potential funders(Required)

I agree that the Foundation may share the information provided in this expression of interest with other potential funders and/or partners.

Yes

Certification of principal researcher(Required)

I certify that if any of (a) – (e) above are relevant and I/we am/are successful in obtaining a grant, the research will not commence until it has been approved by the relevant institutional committee. Successful applicants will be asked to provide evidence of such approval before grants are paid.

Yes

Certification by the Head of Department(Required)

I certify that the Head of department has confirmed this project is appropriate to the general facilities of the department and is prepared to have the project carried out and/or project managed by the department.

Yes

Short survey

I have attended a recent online Q&A session?

Yes

I have attended a presentation by NFMRI at my institution?

Yes

Please complete our speaker request form if you would like to invite NFMRI to present at your institution. https://nfmri.org.au/events/upcoming-events/speaker-request-form/

Upload data and charts

You may upload a single page PDF of data and charts to support your EOI. Please ensure the name of the file includes the name of the Chief Investigator.

Accepted file types: pdf, Max. file size: 30 MB.

Check and submit

Please ensure that you have read the information available on our website including eligibility requirements and uploaded the data file before submitting