Advancing new research

The Interlaken Leadership Awards

Application process

Application form

The next deadline for submission of applications is: June 1, 2015.

*required fields
I have previously submitted a Letter of Intent and have been invited to complete a full application*
 
Reference number (from invitation) *
Name of principal investigator *
Full contact information of principal investigator, including institution and street address *

Telephone number *
Fax number
E-mail address *
Names of co-investigators (if applicable)
E-mail addresses of co-investigators (if applicable)
Institution where proposed research will be conducted *
Official Signing for applicant organization
Name:*
Title:
Telephone:
Fax:
E-mail: *
Title of proposed research *
Type of study:*
Primary aim of study *
Secondary aim(s) of study
Primary end point *
Secondary end point(s)
Number of study subjects/animals
Sample size rationale *
Please attach your curriculum vitae (Word or PDF format). *
Please attach your research protocol (Word or PDF format). *
The protocol must use the standard CSL Behring template, which can be downloaded using this link.
Protocol must include itemized budget in US dollars and timeline.
Estimated funding requirement in US Dollars
(including salary, overhead and direct costs, but excluding product) *
Estimated contribution (%) to funding requirement from:
Salary:*
Overhead: * (not to exceed 35%)
Direct Costs: *
Please select study drug (a selection is required for eligibilty)*
Will your study involve the use of placebo?*
Please describe (if applicable) the blinding methods that you plan to use.
Project duration (Months) *
Start date *
End date *
Anticipated plan for presenting and publishing data
 Meeting abstract / poster (please specify)

 Journal article (please specify)

 Other (please specify)
Please attach any required official approval for application submission from an authorized official
at your institution (Word or PDF format). *
 
Please describe any independent funding that will be sought, if any, from governmental or any other agencies, to supplement funding of this study *
Please briefly describe the facilities that you will be using to conduct this study,
including their capacity, proximity, and availability*
Please briefly describe the scientific environment in which you will be conducting this study, including the level of support or any specific expertise/effort from collaborators and/or from your institution*
If your trial involves human subjects, will it be conducted in a dedicated clinical research unit?*
For trial involving human subjects, do you have an experienced research/study coordinator?*
For trial involving human subjects, have you previously submitted (as the Principal Investigator) a study proposal and consent forms to an IRB/ethics committee, or do you have a coordinator who will do this?*
Please briefly describe your previous experience writing research protocols
and then guiding them through ethics committee approval processes*
If your study involves animals, have you previously submitted (as the Principal Investigator)
an animal care and use protocol to your appropriate institutional committee(s)?*
Do you have a research pharmacy capable of properly storing and tracking study drug
(and placebo if required)?*
If your project involves high capacity computing and/or sequencing, please describe in detail where and how this will be accomplished, and be sure all costs are included in the budget.
Does your study involve multiple sites?*
I certify that I have the necessary qualifications, skills, and experience to conduct this study as it is being proposed. I also certify that I will have the necessary resources to conduct this study as it is being proposed, including (but not necessarily limited to) personnel, institution, and equipment.  
Please indicate that you acknowledge and consent to the following: *
“I understand that my submission will be reviewed by an internal committee at CSL Behring, and that if the committee decides not to fund the project at any step in the review process, the information in the submission will be destroyed confidentially by CSL Behring and no further use of the submission will be made by CSL Behring.
I certify that the statements herein are true, complete, and accurate to the best of my knowledge.”
I have read and agree to these conditions.