Scientific projects

A. Name of the applicant requesting the funding

Name of applicant

Job title

Street

Numberyour full name

Cityyour full name

State / Provinceyour full name

Postal / Zip Codeyour full name

Countryyour full name

Phone Numberyour full name

Email

Short CV

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B. Proposed project

Is the person responsible for the project different to the person named in box A?

YesNo

Name of person

Job title

Street

Number

City

State / Province

Postal / Zip Code

Country

Phone Number

Email

C. Background of the project – narrative summary

Title of the project

0 /

Please provide a comprehensive description of your project. The application will be assessed under the following headings: Background and hypothesis; Specific aims and objectives; a Needs Analysis with evidence of unmet need and Innovation; Approach and Methodology; ie numbers recruited, ethical approval. inclusion & exclusion criteria; Expected outcomes; Impact it will or may have in the field of contraception, sexual and reproductive health; Feasibility (1000 words)

0 /

Timeline: When will it start / finish? (Max 20 words)

0 /

Where will it take place – country / town, establishment? (Max 20 words)

0 /

Sector in the area of contraception, sexual and reproductive healthyour full name

Is this a new Project?

YesNo

If extension of an existing programme, provide information on original programme (Max 50 words)

0 /

Do you foresee any reasons (political, climatic, etc) why this project may be adversely affected? (Max 20 words)

0 /

D. Financial related information

How much will this project cost?

0 / 500

How much are you requesting from ESC?

0 / 500

Are there other partners or organisations supporting this same project?

YesNo

If YES - name the other partners who will support this project (Max 20 words)

0 / 200

Have you already obtained any funding or still awaiting a response towards this project?

YesNo

Are you still awaiting a response towards this project? (Give details in the table below)

YesNo

Details of your proposed budget

Example of costs include: staffing; involvement of a statistician; language editing; costs related to a questionnaire or obtaining relevant reference material. Costs for equipment may sometimes be accepted, dependent on the reason given. Receipts may be requested. Grant money cannot be used for congress registration. List each item required for this project. For each budgetary item, enter either the amount requested from the ESC or if there is also funding from another partner, list the amount & name of partner.

Please list all items required for his project separately:

Item, Amount requested from ESC, Amount requested from additional partner, Name of partner, Any comments

Item, Amount requested from ESC, Amount requested from additional partner, Name of partner, Any commentsyour full name

Total amount requested from ESC

Total amount requested from partner(s)

Add any additional information heremore details

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The ESC may not be in a position to fully fund all applications; you must indicate whether / how part funding may impact your project. (Max 100 words)more details

0 /

Who will oversee the budget & keep accounts? Provide name, title, contact number and email addressmore details

0 /

Note: The ESC retains the right to be refunded any unspent money from the grant.

E. Previous funding from ESC

If you or your department has received funding from ESC for a project or course before, please give details of the date of funding, contact person and title of project or course.more details

0 /

F. Follow up

We, as responsible agents for this project, agree to the following 8 points:

We agree that all monies will be spent appropriately

We agree to work with the nominated Mentor

We agree to advise you at the earliest time if this project is delayed or cannot be completed

We agree to provide an interim report(s) part way through the project and a final report to the ESC within 6 months of the end of the project.

We agree to provide the ESC with an interim budget(s) and a detailed budget at the end of the project. NOTE funding will be awarded in stages and will be dependent on appropriate reporting.

We agree to provide receipts for monies spent if requested.

We agree that if we need to make any significant changes to the duration, contents or funding of the project after it has been awarded, I/we will advise the nominated mentor.

We (the applicant) agree to acknowledge the ESC as a donor in any publications, submission of abstracts and oral communications resulting from this project. Please inform the ESC Office where and when the data is to be presented and/or published and note that ideally any manuscript should be sent to the ESC journal in the first instance.

First Name 1

Last Name 1

Submission date of this form

Questions? ESC Central Office: info@escrh.eu / Tel. 0032 2 582 08 52

Scientific projects

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