Application
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Innovative Therapies Program
Application
Innovative Therapies Program
1
Applicant Information
2
Institution Information
3
Areas of Study
4
Project Information
Applicant Information
Applicant Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Applicant Email
*
Applicant Phone
*
Co-Applicant Names
First Name
Last Name
Principal Applicant (PI) Name
*
First
Last
PI Email
*
PI Location
*
Canada
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Name of Institution
*
Please check to ensure that your institution is in good standing and approved to receive funding -
CRA Approved Institutes
Is this a re-submission?
*
Please do not re-submit an Innovative Therapies grant more than twice.
Yes, this is a re-submission
No
Institutional Financial Contact Person
Name
*
First
Last
Email
*
Phone
*
Trial descriptors
Intervention Type
*
Please select all that apply
Counselling
Music-, art-, play-, animal- or biblio-therapy
Physio-, exercise- or occupational therapy
Nutritional
Surgical
Radiation
Alternative health therapy
Small molecule
Complex therapies (e.g. enzyme therapy, live organisms)
Antibody
Genome or Transcriptome Editing
Other
Other Intervention Type
Please specify.
Interventional Trial Methodology
*
Please select all that apply
n of 1
Open label
Historical controls
Cohort
Case-control or Matched pair
Randomized
Placebo or Sham controlled
Single blind
Double blind
Adaptive
Cross-over
Factorial
Withdrawal
Stratification
Superiority
Non-inferiority
Project Information
Project Title
*
Lay Language Project Summary
*
Patient or parent reviewers will use this section to assess your application. If approved, this section will be posted online immediately so please do not include any proprietary or patient-identifying information.
Click here to get more information about our lay summary guidelines.
(Max 2000 characters including spaces)
Scientific Summary
*
Scientific/medical reviewers will use this section to assess your application. (Max 2800 characters including spaces)
References
*
Please add references in Vancouver style Author (year) "Title" Journal X;xxx-yyy Please do not highlight any names in the references.
Upload Images
*
Please note upload limit of 2 images. Please include captions in images.
Drop files here or
Accepted file types: jpg.
Power
*
Power is the probability of obtaining a true positive result from your trial. We understand that power calculations are usually not feasible in pilot trials but please briefly discuss the ways your trial is structured, and/or how your readouts, and/or the confounders you will control for, etc. you get the picture, that will increase the likelihood of a true positive result (and/or decrease the likelihood of a false negative result).
Patient Safety
*
Please discuss: 1) How will patients be monitored and what will you be looking for to maximize patient safety? 2) Who is directly responsible for reviewing all adverse events and serious adverse events in the trial and how will these be captured and recorded? Who is responsible for assessing the overall risk-benefit of the intervention during the course of the trial? 3) Name the predictable negative consequences or side effects of the therapy, if any. 4) Will ethics approval be required by your intuition?
Total Funds Requested $(CAD)
*
Please only ask for what you need. We only fund trials where we are the majority funder. Maximum request is currently $20,000 Canadian dollars.
Please enter a number from
1
to
20000
.
Terms
By clicking submit below I agree to the following terms, if funding is provided: - I agree to send in a one to two paragraph lay summary describing the results upon study completion. - I agree to acknowledge the support of the Rare Disease Foundation and BC Children’s Hospital Foundation in any resulting publication(s).
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