ALLEGATO B1 PROGETTO parte di Programma Strategico FORM 1 FORM 1 General information about the project INSTITUTION PRESENTING THE STRATEGIC PROGRAM (DESTINATARIO ISTITUZIONALE PROPONENTE): TITLE OF THE PROJECT (MAX 300 WORDS) \ \ PROJECT COORDINATOR OF THE STRATEGIC PROGRAM * \ \ PROJECT PART OF A STRATEGIC PROGRAM SPECIFY THE TITLE OF THE STRATEGIC PROGRAM TO WHICH THIS PROJECT BELONGS TOTAL BUDGET OF THE PROJECT / / / / / / / / FUNDING REQUIRED TO THE MINISTRY OF HEALTH / / / / / / / / INSTITUTIONAL RESOURSES / / / / / / / / CO-FUNDING FROM OTHER SOURCES : / / / / / / / / (SPECIFY THE CO- FUNDING INSTITUTION, STARTING DATE OF ITS AVAILABILITY AND ITS AMOUNT) / / / / / / / / / / / / / / / CO-FUNDING INSTITUTION DD MM YY AMOUNT / / / / / / / / / / / / / / / CO-FUNDING INSTITUTION DD MM YY AMOUNT ---------------------------------------------------------------------------------------------------------------------------------- * THE NEXT PAGE OF THIS FORM SHOULD BE FILLED IN I
FORM 1 THIS PAGE SHOULD BE FILLED ONLY BY THE COORDINATING PROJECT Short description of the general and specific objectives of the Strategic Program (SP) (Indicate the main objectives of the Strategic Program (SP) with a concise account of how the individual Projects part of the SP will contribute to them. Clarify the added value of the collaboration among the Projects in terms of shared methodologies and knowledge(s) that will be obtained - max. 3500 characters). Short description of the organisational structure of the Strategic Program (SP) (Indicate how the coordination among the Projects will be organised, whether a Steering and/or Avisory Board (s) will be appointed and any other technical information that may be relevant to assess the added value of the coordination (max. 1000 characters). II
SCIENTIFIC COORDINATOR: Name and Surname Istitution : Professional status: : Address : Tel number : Fax number: E-mail address: ADMINISTRATIVE COORDINATOR (TO BE FILLED ONLY BY REGIONI, PROVINCE AUTONOME E AGENZIA DEI SERVIZI SANITARI REGIONALI): Name and Surname Istitution : Professional status: : Address : tel Number : Fax number: E-mail address: LIST OF PARTICIPATING UNITS (UNITÀ OPERATIVE COINVOLTE): Name of the Institutions and of their Legal Representative (if needed an attachment should be added) III
FORM 2 FORM 2 DESCRIPTION OF THE PROJECT (SUMMARY OF THE ACTIVITIES OF ALL THE PARTICIPATING UNITS (UNITÀ OPERATIVE) WHAT IS ALREADY KNOWN ON THE SUBJECT (INCLUDE THREE RELEVANT REFERENCES IN PEER REVIEWED JOURNAL) (MAX 20 LINES) WHAT THE PROJECT ADDS TO THE INFORMATION ALREADY AVAILABLE (MAX 10 LINES) FORM 2 IV
DETAILED DESCRIPTION OF THE PROJECT S MAIN AND SECONDARY OBJECTIVE (S) (max 40 lines ) V
METHODS (max 2 pages) FORM 2 SPECIFY: (whenever applicable) a) Patients/population; b) Intervention(s)/Analytical procedures; c) Indicator(s); d) Study design; e) Statistical analysis VI
METHODS (cont d) FORM 2 VII
FORM 2 GENERAL TRANSFERIBILITY AND POTENTIAL IMPACT OF RESULTS (max 1/2 page) OUTPUT(S) OF THE PROJECT (DESCRIBE THE OUTPUTS THAT THE PROJECT WILL PRODUCE SPECIFYING WHEN - DURING THE PROJECT - THEY WILL BECOME AVAILABLE Example(s) of output: ANIMAL MODELS, METHODOLOGIC WORKPACKAGES, OTHER DELIVERABLES VIII
MILESTONES ALONGSIDE THE PROJECT FORM 2 (Max 1 page) (LIST UP TO TEN MILESTONES WITH RELEVANT RESULTS EXPECTED DURING THE PROJECT) IX
FORM 2 TIMETABLE OF THE PROJECT (Describe the phases of the project for each Participating Unit (Unità Operativa); include a Gantt diagram) (Max 2 pages) X
TIMETABLE (cont d) FORM 2 XI
COORDINATING COST OF THE PROJECT FORM 2 Costs items and brief description Total Part covered by MoH* funds (see footnote 1) 1. Permanent staff None 2. Project Staff (ad hoc contracts/consultants/fellowship) 3. Travel Costs and Subsistence Allowances 4. Equipment 5. Consumables and Supplies directly linked to the Project 6. Dissemination of results (publications, meetings/workshops etc.) _ 7. Data handling and analysis (specify) 8. Program coordinating costs* (see footnote 2) 9. Overheads for all Institutions involved (specify) TOTAL --------------------------------------------------------------------------------------------------------------------------------------------------- *1) MoH = Ministry of Health *2) Solo per il Progetto Capofila del Programma Integrato XII
OVERALL COSTS OF THE PROJECT FORM 2 Costs items and brief description Total Part covered by MoH* funds (see footnote 1) 1. Permanent Staff none 2. Project Staff (ad hoc contracts/consultants/fellowship) 3. Travel Costs and Subsistence Allowances 4. Equipment 5. Consumables and Supplies directly linked to the Project 6. Dissemination of results (publications, meetings/workshops etc.) 7. Data handling and analysis (specify) 8.. Program coordinating costs 9. Overheads for all the Institutions involved (specify) TOTAL ------------------------------------------------------------------------------------------------------------------------------ *1) MoH = Ministry of Health XIII
CV of the Scientific Coordinator of the project (REPORT UP TO 10 REFERENCES FROM THE LAST 5 YEARS RELEVANT TO THE TOPIC AREA OF THIS PROPOSAL) FORM 2 (max 1 page) XIV
FORM 2BIS FORM 2 BIS: DESCRIPTION OF EACH PARTICIPATING UNIT (UNITÀ OPERATIVA) CONTRIBUTION TO THE PROJECT (One form per Participating Unit should be filled ) PARTICIPATING UNIT SCIENTIFIC COORDINATOR : Name and Surname: Institution : Professional status: Address : Tel number: Fax number: E-mail address: AUTHORISED LEGAL REPRESENTATIVE Name and Surname : SPECIFIC CONTRIBUTION OF THE UNIT TO THE PROJECT (max 20 lines) XV
METHODS SPECIFY (whenever applicable): a) Patients/population; b) Intervention(s)/Analytical procedures; c) Indicator(s); d) Study design; e) Statistical analysis (max 1 page) FORM 2 BIS XVI
FORM 2BIS PERSONNEL Dedicated to the Project activities (in person-months): 1.Position: (permanent staff/project staff) qualification*: (see footnote 1) person-months dedicated: 2.Position: (permanent staff/project staff) qualification*: (see footnote 1) person-months dedicated: 3.Position: (permanent staff/project staff) qualification*: (see footnote 1) person-months dedicated: 4.Position: (permanent staff/project staff) qualification*: (see footnote 1) person-months dedicated: Equipment of participating units dedicated to the project: ------------------------------------------------------------------------------------------------------------------------------ * 1 Example: physician/nurse/statistician/health economist/biologist etc. XVII
FORM 2BIS COSTS OF THE PARTICIPATING UNIT Costs items and description Total Part covered by MoH* funds (see footnote 1) 1. Permanent Staff none 2. Project Staff (ad hoc contracts/consultants/fellowship) 3. Travel Costs and Subsistence Allowances 4. Equipments 5. Consumables and Supplies directly linked to the Project _ 6. Dissemination of results (publications, meetings/workshops) 7. Data handling and analysis (specify) 8. Overheads (specify) TOTAL ------------------------------------------------------------------------------------------------------------------------------ *1) MoH = Ministry of Health XVIII
FORM 2BIS CV of the Scientific Coordinator of the Participation Unit (Unità Operativa) (max 1 page) (REPORT UP TO 10 REFERENCES FROM THE LAST 5 YEARS RELEVANT TO THE TOPIC AREA OF THIS RESEARCH PROPOSAL) XIX