EQUIPMENT GRANT APPLICATION FORM VER3.0

This application form should be used for applications to Moorfields Eye Charity under the Equipment Grant funding scheme.

Please use the Equipment Grant Guidance Notes when completing the application form. The guidance notes provide more detailed advice about what information is required in each section of the application form.

Please ensure that you complete all relevant annexes and attach the budget to the final pdf

REQUIRED FOR ALL APPLICATIONS ANNEX A Project grant budget (excel file)

COMPLETE WHEN APPLICABLE

ANNEX B Collaborator Form

ANNEX C Additional information for clinical/translational research

ANNEX D Additional information for research involving animals

REQUIRED FOR ALL APPLICATIONS ANNEX E Research office approval Form

Completed applications must be submitted to the Charity Office by the published deadline via email to researchgrants@moorfields.nhs.uk and contain the following:

(1) Application form (as word document) (2) Budget sheet (Annex A) (as excel file) (3) Scanned copy of signed Annex E (PDF/TIFF)

For any queries regarding your application please contact:

Dr Ailish MurrayGrants Manager, Moorfields Eye CharityTelephone: 020 7566 2632 ailish.murray@moorfields.nhs.uk

EQUIPMENT GRANTAPPLICATION FORM

SECTION 1: APPLICATION SUMMARY DETAILS

Q1. PRINCIPAL APPLICANT (Title / Name)

Q2. PROGRAMME TITLE (max 20 words)

Q3. START DATE (dd/mm/yyyy)

Q4. DURATION (months)

Q5. BUDGET SUMMARY

(a) Amount requested in this application £

(b) Amount secured/to be secured from other source(s) £

(c) Total Project Cost £

(d) Will a Restricted Donation(s) be accessed for part of this funding? (delete one) Yes / No

(e) Is this application seeking funding to supplement a currently held and active award? (delete one) Yes / No

Q6. HOST INSTITUTIONMoorfields Eye Hospital UCL Institute of Ophthalmology

Other – please specify

Q7. CATEGORY OF RESEARCH PROPOSED Please select one only

Pre-clinical / basic research Translational research / proof of concept to phase IIa trials

Post phase IIa trials Other (e.g. cross-over from pre-clinical to translational, patient welfare, healthcare services). Please provide brief details (max 50 words)

Q8. AREA OF RESEARCH PROPOSED Select area(s) (max 2) that relate to the largest theme(s) of the proposal

AMD Corneal / ocular surface disease Community health / rehabilitation / patient support

Diabetic retinopathy Glaucoma Lens / cataract

Neuro-ophthalmology / optic neuropathies Ocular cancer Paediatrics

Ocular inflammatory diseases Ocular motility / visual processing

Genetics / Inherited eye disorders Retinal / Vitreo-retinal

Q9. JOINT MEH/IoO RESEARCH STRATEGY (please select one from (a) and (b) as applicable)

(a) Disease Glaucoma AMD Diabetic retinopathy

Inherited eye disease / rare diseases

(b) Treatment / approach Cell therapy Informatics Imaging Gene therapy

Other (max 100 words)

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SECTION 2: SUMMARY OF PROPOSAL

Q1. STRATEGIC FIT AND ENHANCEMENT OF RESEARCH AND CLINICAL PRACTICE (max 150 words)

Q2. SUMMARY, FOR SCIENTIFICALLY QUALIFIED ASSESSORS, OF EQUIPMENT REQUESTED AND THE RESEARCH IT WOULD SUPPORT (To include key research question(s), aims & objectives - max 150 words)

Q3. SUMMARY FOR LAY READERS (max 150 words)

Q4. DEMAND AND IMPORTANCE (max 150 words)

Q5. SCIENTIFIC AND TECHNICAL MANAGEMENT. (max 200 words)

SECTION 3: RELATED GRANTS & APPLICATIONS

Q1 DETAILS OF APPLICATIONS TO AND AWARDS FROM FUNDING BODIES WITH FINANCIAL INPUT TO THIS PROPOSAL.

Please include (for each application / award as relevant) Name of funding body Title of project and brief description of how the grant relates with the current application (max 100 words) Total value of award and value of the contribution to work related to this application Start/end dates / Expected date of outcome (for submitted applications)

For co / matching funding requests please also address the questions below based on type of request:

For applications that propose to support a new, discrete, piece of research which is part of a larger funded project Why was this piece of research / funding requirement not presented in the original application? Was supplement funding requested from the original funder? If no, why not? Could funding be secured from another external funding body? What is the added value to the overall research project and to MEC in funding this additional piece of work at this

time?

For applications that are requesting top-up funding to support an already funded project (i.e. there are no new elements to the research proposal) Why was the full cost of the research project not requested within the original application (if the funding call was

capped, please provide details) Could funding be secured from the original funding body via a different call or another external funding body? If

yes, why has this not been done? If awarded, what, if any, element(s) of the current proposal could be attributed to MEC’s support? What is the added value to MEC in providing additional funding to an already funded project?

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Q2. APPLICATIONS WITH NO FINANCIAL INPUT FROM OTHER FUNDING BODIESPlease provide details of how you could secure funding from a recognised charity to support this programme

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SECTION 4: PRINCIPAL APPLICANT DETAILS AND CV in total section 4 must not exceed 3 sides of A4

Q1. CONTACT INFORMATION

Name and Title

Current post(s) (include employer name)

Address (department name and location)

Email address Contact telephone number

Time spent on research (hrs per week) Time spent on this grant (hrs per week)

Q2. PREVIOUS POSTS HELD (most recent first, maximum 5 entries)

Date from mm/yyyy Date to mm/yyyy Position Organisation

Q3. EDUCATION AND TRAINING (most recent first, maximum 5 entries)

Date awarded mm/yyyy Qualification Subject Organisation

Q4. GRANT APPLICATIONS TO SPECIAL TRUSTEES OR MOORFIELDS EYE CHARITY State title of project, role on the grant (e.g. PI, Co-PI), amount requested and grant application number if known.

(a) Awarded grantsPlease list grants (most recent first) held in the last five years or any key prior grants.(b) Unsuccessful applicationsPlease list applications in the last five years which were not awarded.

Q5. AWARDED GRANTS FROM OTHER FUNDING AGENCIESPlease list grants (most recent first) held in the last five years or any key prior grants. State name of awarding body, title of project, role on the grant (e.g. PI, Co-PI), amount awarded, and start/end dates.

Q6. PUBLICATIONSPlease list all (or key) publications from the last five years including original research publications and other scholarly contributions. Publications should be in chronological order with the most recent first. Max 1 side of A4

Q7. KEY RESEARCH/SCIENTIFIC/CLINICAL CAREER ACHIEVEMENTSPlease provide a summary of key research/scientific/clinical achievements to date that are NOT listed elsewhere in the application. Max 200 words

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SECTION 5: CO-APPLICANT DETAILS AND CV in total section 4 must not exceed 3 sides of A4 per person

Q1. CONTACT INFORMATION

Name and Title

Current post(s) (include employer name)

Address (department name and location)

Email address Contact telephone number

Time spent on research (hrs per week) Time spent on this grant (hrs per week)

Q2. PREVIOUS POSTS HELD (most recent first, maximum 5 entries)

Date from mm/yyyy Date to mm/yyyy Position Organisation

Q3. EDUCATION AND TRAINING (most recent first, maximum 5 entries)

Date awarded mm/yyyy Qualification Subject Organisation

Q4. GRANT APPLICATIONS TO SPECIAL TRUSTEES OR MOORFIELDS EYE CHARITY State title of project, role on the grant (e.g. PI, Co-PI), amount requested and grant application number if known.

(a) Awarded grantsPlease list grants (most recent first) held in the last five years or any key prior grants.(b) Unsuccessful applicationsPlease list applications in the last five years which were not awarded.

Q5. AWARDED GRANTS FROM OTHER FUNDING AGENCIESPlease list grants (most recent first) held in the last five years or any key prior grants. State name of awarding body, title of project, role on the grant (e.g. PI, Co-PI), amount awarded, and start/end dates.

Q6. PUBLICATIONSPlease list all (or key) publications from the last five years including original research publications and other scholarly contributions. Publications should be in chronological order with the most recent first. Max 1 side of A4

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SECTION 6: DETAILS OF PROPOSAL

Describe of the equipment and researchPlease include (i) details of the equipment requested including scientific rationale/justification for the type and model of equipment (ii) if appropriate, details of similar equipment in the applicants’ departments / local departments and the reasons why it cannot be used for the purposes described (iii) names/locations of applicants and other potential users and a short description of their work that the research would support (iv) added value the equipment would bring to MEH/IoO

A maximum of 2,000 words, excluding references

Images/figures/schematics may be embedded in the text or submitted as part of an appendix (maximum 2 sides of A4) to this section.

References must be included – give full citation including title, journal title and list all authors (use of el al is only appropriate where there are >10 authors)

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SECTION 7: MILESTONES, DATA MANAGEMENT AND SHARING

Q1. MILESTONES: All applications, irrespective of duration or funding level, must complete this section. However, the detail provided is expected to be proportional to the duration and level of funding.

Please include (table expandable to max 1 side of A4 OR Gantt chart (1 side of A4) attached to application) Dates for purchase of equipment and set up time Objectives, dates they should be achieved Possible outputs - publications (journal and submission dates), presentations / conferences, outcomes /

innovations for clinical use

Milestone (title and description) Date (mm/yyyy)

Q2. DATA MANAGEMENT AND SHARING Where appropriate, detail (a) your plans for data management, curation and storage (b) your policy for sharing data with others, including the management and prioritisation of access to data (c) your strategy for current and future communication with user communities and (d) any ethical considerations (max 300 words)

SECTION 8: BUDGET DETAILS

The excel file ‘ANNEX A – EQUIPMENT GRANT BUDGET’ must be completed and submitted with the completed grant application.

Please refer to guidance notes when completing this section. All costs must be approved by an appropriate authority at MEH and UCL IoO and if necessary any other academic/clinical partner institution involved in the project.

Q1. CO-/MATCHING FUNDING COSTS. Where an application is for co-/matching funding to a grant awarded/requested from another funding body, please provide a breakdown of the funding awarded/requested. Please include budget category descriptions (e.g. salary, equipment) and value (£).

Budget category (title / description) Amount awarded / requested

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SECTION 9: BUDGET JUSTIFICATION

All costs must be justified with respect to the equipment requested

Q1. EQUIPMENT COSTS (max 300 words)

Q2. MATERIALS AND CONSUMABLES (max 300 words)

Q3. SALARY COSTS (max 300 words)

SECTION 10: ADDITIONAL INFORMATION

Q1. INTELLECTUAL PROPERTY (IP) / COMMERCIALISATION

Will the proposed research/equipment use technology, materials or other invention that, as far as you are aware, are subject to any patents or other forms of intellectual property protection? If YES, give details (max 200 words)

Yes / No

Is the proposed research/equipment, in whole or part, subject to any agreements with commercial, academic or other organisation? If YES, give details (max 200 words) Yes / No

Is there any potential for patents or commercially exploitable results from this research/equipment? If YES, give details (max 200 words) Yes / No

If this research is successful will it provide added value e.g. new tools, drugs, biological materials, methods of treatment etc. that add value to eye health through a product, drug, vaccine etc. that should be protected because it will make money for the owner? If YES, please describe what this added value is (max 200 words)

Q2. RESEARCH INVOLVING HUMAN PARTICIPANTS AND/OR ANIMALS

Does this project involve human participants and/or biological samples? (delete one) Yes / No

If YES, please complete ANNEX C

Will your project involve use of animals? (delete one) Yes / No

If YES, please complete ANNEX D

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SECTION 11: PRINCIPAL APPLICANT SIGN OFF

By signing this section, the Principal Applicant, confirms that he/she have complied with the instructions for completing and submitting this application and if the application is funded he/she will agree to the terms, conditions and processes of Moorfields Eye Charity.

Q1. CONSULTANCIES, EQUITIES AND DIRECTORSHIPS

Do you have consultancies or any equity holdings in, or directorships of, companies or other organisations that might pose a conflict of interest to the current application? If YES, give details (max 100 words) Yes / No

Q2. PRINCIPAL APPLICANT SIGN OFF DETAILS

Name (print)

Signature (electronic)

Date (dd/mm/yyyy)

Q3. EXTERNAL PEER REVIEW

(a) Proposed external peer reviewers. Please provide the names and contact details (address and email address) for 3 potential external reviewers. These must not include colleagues from your organisation or those with whom you have published/collaborated with in the last 3 years

The Charity may or may not choose to approach some, or all, of the individuals you have selected

Reviewer 1

Reviewer 2

Reviewer 3

Reviewer 4

(b) Peer review restrictions. If you do not wish the Charity to approach certain people or institutions, please provide the name / details below

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ANNEX B: COLLABORATOR FORM

A separate form should be duplicated for each collaborator / collaborating group. Collaborators, in this context, are scientific/medical/academic colleagues who are associated with a research proposal and named in the body of the application but who are not co-applicants. They are not usually involved in the day-to-day running of the project for any length of time and usually contribute expertise or material towards a discrete piece of work on the project.

PRINCIPAL APPLICANT (name/title)

PROJECT TITLE

COLLABORATOR DETAILS

Name and Title

Address (department name and location)

Email address

Role / contribution to the project (max 100 words)

Please indicate if there are any Intellectual Property issues or restrictions arising from Material Transfer Agreements (max 100 words)

COLLABORATOR

Name (signature*)

Date (dd/mm/yyyy)

*electronic signature is sufficient

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ANNEX C: ADDITIONAL INFORMATION FOR CLINICAL/TRANSLATIONAL RESEARCH

Q1. BRC RESEARCH THEMES (please select one)

Regenerative medicine & pharmaceutics Paediatrics & Inherited eye disorders

New technologies & devices Genotyping, Phenotyping & informatics

Inflammation & immunotherapy Gene therapy

Visual assessment & imaging Not applicable

Q2. NIHR CLINICAL RESEARCH NETWORK (CRN) PORTFOLIO

(a). Has this project have national ethics approval? (delete one).If YES, please provide details... If NO please provide details of how/when this will be secured (max 100 words)

Yes / No

(b) Will this project be adopted on to a NIHR portfolio? (delete one) Yes / No

(c) If this project is registered, please provide the portfolio number

(d). If this project is NOT registered, please provide exact details of how you will ensure registration can and will be secured. (max 100 words)

Q3. RESEARCH & DEVELOPMENT (NON-COMMERCIAL) RESEARCH STUDY SET-UP

a. (a) Is this project a/part of a non-commercial research study for which MEH will be sponsor? (delete one) Yes / No

(b) Has NHS permission been granted? Yes / No

If YES, what is the reference and when was permission granted (mm/yyyy)

If NO, please provide details of where application is currently at in the approval process? (delete one)

Q4. RESEARCH ACTIVITY RECORD (WHERE RELEVANT TO THE PRINCIPAL APPLICANT)

(a) What is your record of recruiting patients to target in any clinical research trial for which you are the Chief Investigator?

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(b) What is your record of referring patients to colleagues for potential recruitment to clinical research trials? If applicable, please provide details.

N/A

(c) What is your record for acknowledging the NIHR’s support (for research infrastructure etc.) in your publications?

100% >80% 50% <50% N/A

(d) What is your record for acknowledging the support of any funding you have received in the last 3 years from the Special Trustees of Moorfields Eye Hospital and/or Moorfields Eye Charity?

100% >80% 50% <50% N/A

(b) What is your record of referring patients to colleagues for potential recruitment to clinical research trials? If applicable, please provide details.

N/A

(c) What is your record for acknowledging the NIHR’s support (for research infrastructure etc.) in your publications?

100% >80% 50% <50% N/A

(d) What is your record for acknowledging the support of any funding you have received in the last 3 years from the Special Trustees of Moorfields Eye Hospital and/or Moorfields Eye Charity?

100% >80% 50% <50% N/A

(e) What is your record for supporting research capacity development?

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ANNEX D: ADDITIONAL INFORMATION FOR RESEARCH INVOLVING ANIMALS

Please complete and attach to application if the proposed research will involve animals and/or animal tissue

Q1. Will your project be governed (fully or in part) by the provisions of the Animals (Scientific Procedures) Act of 1986? Yes / No

Q2. Will your project include procedures to be carried out on animals in the UK which require a Home Office licence? Yes / No

If YES, please give details of why animal use is necessary, how you have considered the three Rs (Replacement, Reduction and Refinement) details and why other possible approaches are not used (max 200 words)

Q3. Please verify that the necessary Home Office project and personal licences are in place and provide the licence number.

Yes / No

If NO, please explain why.

Q4. As part of this project, will experiments be carried out on animals outside of the UK Yes / No

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ANNEX E – RESEARCH OFFICE APPROVAL

All applications must be approved by MEH R&D office even if all the research (and costs) will be carried out at UCL Institute of Ophthalmology (IoO).

Signatures must be signed and not typed and the completed page scanned and submitted as a PDF/TIFF file

Applicants who have selected IoO as the host institution must ensure this Annex is signed by MEH R&D office (Q2) before they submit their application to the IoO Research Office for approval

TO BE COMPLETED BY THE APPLICANT PRIOR TO SEEKING R&D APPROVAL

Will proposed research use facilities / patients at MEH? (tick one) Yes No

Will costs be incurred at MEH? (tick one). If YES, Q1 must be signed Yes No

TO BE COMPLETED BY THE MEH R&D / UCL INSTITUTE OF OPHTHALMOLOGY RESEARCH OFFICE REPRESENTATIVES

We, the undersigned, confirm approval for submission of this application on the basis of the costs outlined in the attached application We indicate below any conditions attached to our approval. We understand that if this application for funding is successful, the principal host institution (as named in Section 1) will be required to confirm acceptance of the Moorfields Eye Charity terms, conditions and reporting processes. We agree, where we represent collaborate institutions to provide in a timely fashion, any information required by the Moorfields Eye Charity or the principal host institution.

Q1. MOORFIELDS RESEARCH FINANCE REPRESENTATIVE APPROVAL

Name {signature) Date (dd/mm/yyyy)

Have you reviewed Annex A - Budget (excel file) for this application? (tick one) Yes ☐ No ☐

Do you approve this application? (tick one) N/A (no MEH costs) ☐ Yes ☐ No ☐

Comments/Conditions

Q2. MOORFIELDS RESEARCH & DEVELOPMENT OFFICE REPRESENTATIVE APPROVAL

Name {signature) Date (dd/mm/yyyy)

Do you approve this application? (tick one) N/A (no MEH component) ☐ Yes ☐ No ☐

Comments/Conditions

Q3. UCL INSTITUTE OF OPHTHALMOLOGY RESEARCH OFFICE REPRESENTATIVE APPROVAL

Name {signature) Date (dd/mm/yyyy)

Do you approve this application? (tick one) Yes ☐ No ☐

Comments/Conditions

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