ANNEX III INCOCOPERNICUS 1997/1998 APPLICATION FORM 1 FOR COMMISSION USE P L 3 1 1 4 PART A : FINANCIAL AND ADMINISTRATIVE INFORMATION A1. ADMINISTRATIVE SUMMARY ( To be completed by the project Coordinator ) Joint Research Project X Demonstration Project 2 Concerted Action Accompanying Measures Research Sector (see chapter 1 of the Infopack) Mark a cross in only one Research Sector and only one Subsector 1 2 3 X 4 5 6 7 8 9 10 Subsector 1 X 2 3 4 * Title of the project ( and Acronym ) : ASSESSMENT AND ECONOMIC ANALYSIS OF HEALTH CARE SYSTEM IN... * Information about: Project Coordinator Scientific Coordinator (if different from the project coordinator) Name: [J. MERTENS Name: [ P. VLADIMIR Country Code: [B Country Code: [ SI * Project duration (in months) (2) : [ 36 * Summary Table (if more partners are involved use an additional page) (3) : Organization name (5) Role (4) Country code (6) Total Cost (kecu) (7) Requested EC Contribution (kecu) (8) 1 Universiteit van Gent CO B 45 45 2 Slovenska Botsjan Fundacija CS SI 35 35 3 Institut National de Recherche Médicale CR F 40 40 4 Spanisch Immunotechnology CR E 20 10 5 Institute of Medical Research CR PL 40 40 6 National Academy of Health CR HU 30 30 7 Medical University of Kaunas CR LT 25 25 8 9 10 0 Number of PART A pages (only A1 administrative summary) 1 Number total of partners 7 Totals 235 225 Has this or a similar proposal been submitted (now or in the past) to any other European Community programme, INTAS or any other agency for financial support? (Specify the proposer, the programme, date of submission and the financial support obtained, if any) : NO 1 For explanation of numbers between brackets see Annex IV 2 Only for sector 4: nonnuclear energy Name, date and signature of the Project Coordinator on behalf of all proposers 28.08.97 J. Mertens
FOR COMMISSION USE C 1 3 1 1 4 A2. ADMINISTRATIVE DETAILS Coordinator(s) Full coordinates of the project coordinator (4) Name :[Mertens First name :[Jack Legal Name of the organization carrying out the research: [ Universiteit van Gent Faculty of Sciences Street Name and n : [Heidelberglaan, 32 Town: [Gent Postal Code / Cedex : [ 9000 / [ P.O Box : [ Country code (6): [ B Telephone number (country and area code) (11): [+32 9 733 69 68 Telefax : [ +32 9 733 14 15 email: [uvg@fac.sciences.be Name of the scientific coordinator for the proposed research (4) : Name :[ Vladimir First name :[ Petr [ Street Name and n : [ Town: [ Postal Code / Cedex : [ / [ P.O Box : [ Country code (6): [ Telephone number (country and area code) (11): [ Telefax : [ email: [ Administrative responsible for the signature of a contract within the body (9) : Name :[ Jean Paul Coenen (RECTOR OF THE UNIVERSITY OF GENT) Office address (if different from the address given above) (10) Street Name and n : [ Heidelberglaan, 32 Town: [ Gent Postal Code / Cedex : [ 9000 / [ P.O Box : [ Country code (6): [ B Telephone number (country and area code) (11): [ +32 9 733 70 70 Telefax : [+32 9 733 14 15 email: [ uvg@fac.sciences.be Summary table of participants costs ( OF THE PROJECT COORDINATOR): Cost category Total Cost (kecu) (7) Requested EC contribution (kecu)(8) Labour (13) Effort in manmonths 40 16 16 Av. monthly rate (ECU) 400 Travel & Subsistence (17) 8 8 Durable equipment (15) (please describe in the detailed proposal description B2) 10 10 Consumables (18) 6 6 External Services (16) 1 1 Other Expenditures (19) Overheads (14) 4 4 Total (excl.vat) 45 45
FOR COMMISSION USE C 2 3 1 1 4 A2. ADMINISTRATIVE DETAILS Coordinator(s) Full coordinates of the project coordinator (4) Name :[ Mertens First name :[ Jack Legal Name of the organization carrying out the research: [ Street Name and n : [ Town: [ Postal Code / Cedex : [ / [ P.O Box : [ Country code (6): [ Telephone number (country and area code) (11): [ Telefax : [ email: [ Name of the scientific coordinator for the proposed research (4) : Name :[ Vladimir First name :[ Petr [ Slovenska Botsjan Fundacija Department of Health Epidemiology Street Name and n : [ Kabalaya Street, n 56 Town: [ Ljubljana Postal Code / Cedex : [ 61000 / [ P.O Box : [ Country code (6): [ SI Telephone number (country and area code) (11): [ +386 61 345 6789 Telefax : [ +386 61 3 456 788 email: [ slovbo@dept.hel.si Administrative responsible for the signature of a contract within the body (9) : Name :[ Bratny Stefan (DIRECTOR OF THE SLOVENSKA BOTSJAN FUNDACIJA) Office address (if different from the address given above) (10) Street Name and n : [ Volano str. 12 Town: [ Ljubljana Postal Code / Cedex : [ 61000 / [ P.O Box : [ Country code (6): [ SI Telephone number (country and area code) (11): [ +386 61 345 6666 Telefax : [ +386 61 345 7777 email: [slovbo@dept.hel.si Summary table of participants costs : (OF THE SCIENTIFIC COORDINATOR) Cost category Total Cost (kecu) (7) Requested EC contribution (kecu)(8) Labour (13) Effort in manmonths 30 12 12 Av. monthly rate (ECU) 400 Travel & Subsistence (17) 6 6 Durable equipment (15) (please describe in the detailed proposal description B2) 7 7 Consumables (18) 4 4 External Services (16) 3 3 Other Expenditures (19) Overheads (14) 3 3 Total (excl.vat) 35 35 P. Vladimir
FOR COMMISSION USE P 1 3 1 1 4 A2. ADMINISTRATIVE DETAILS Full coordinates of the partner (one page by partner ) Name :[ Legrand (ADMINISTRATIVE OFFICIAL) First name :[ Pierre Legal Name of the organization carrying out the research: [ Institut National de Recherche Médicale Laboratoire de Biologie Street Name and n : [Rue du Bassin, 1456 Bâtiment 12 Town: [ Grenoble Postal Code / Cedex : [ Cedex 38041 / [ P.O Box : [ BP 53 X Country code (6): [ F Telephone number (country and area code) (11): [ +33 476 123 456 Telefax : [ +33 476 123 654 email: [ plegrand@inrm.fr Name of the scientific partner for the proposed research (4) : Name :[ Professor Leroy First name :[ Frédérique [ Institut National de Recherche Médical Laboratoire de Biologie [ Street Name and n : [ Rue du Bassin, 1456 Bâtiment 12, bureau 1/9 Town: [ Grenoble Postal Code / Cedex : [ Cedex 38041 / [ P.O Box : [ BP 53X Country code (6): [ F Telephone number (country and area code) (11): [ + 33 476 123 444 Telefax : [ +33 476 123 654 email: [ Summary table of proposers costs: Cost category Total Cost (kecu) (7) Requested EC contribution (kecu) (8) Labour (13) Effort in manmonths 30 9 9 Av. monthly rate (ECU) 300 Travel & Subsistence (17) 7 7 Durable equipment (15) (please describe in the detailed proposal description B2) 9 9 Consumables (18) 6 6 External Assistance (16) Other Expenditures (19) 5 5 Overheads (14) 4 4 Total (excl.vat) 40 40 Signature (or fax indicating your agreement) : P. Leroy
FOR COMMISSION USE P 2 3 1 1 4 A2. ADMINISTRATIVE DETAILS Full coordinates of the partner (one page by partner ) Name :[ Jimenez (ADMINISTRATIVE OFFICIAL) First name :[ Pablo Legal Name of the organization carrying out the research: [ Spanisch Immunotechnology Street Name and n : [Calle de Madeira, 28 Town: [Madrid Postal Code / Cedex : [ 28020 / [ P.O Box : [ Country code (6): [ E Telephone number (country and area code) (11): [ +34 1 7612 456 Telefax : [ +34 1 476 123 4 email: [ simuno@jimenez.es IND X EDU ROR INT OTH SME Full cost basis (commercial companies) (7) X Additional cost basis (mainly for universities and research establishments) (7) Name of the scientific partner for the proposed research (4) : Name :[ Ing. Martinez First name :[ Xiomin [ Spanisch Immunotechnology [ Street Name and n : [ Town: [ Postal Code / Cedex : [ / [ P.O Box : [ Country code (6): [ Telephone number (country and area code) (11): [ +34 1 7612 444 Telefax : [ email: [ Summary table of proposers costs: Cost category Total Cost (kecu) (7) Requested EC contribution (kecu) (8) Labour (13) Effort in manmonths 20 8 4 Av. monthly rate (ECU) 400 Travel & Subsistence (17) 4 2 Durable equipment (15) (please describe in the detailed proposal description B2) 3 1,5 Consumables (18) 1 0,5 External Assistance (16) Other Expenditures (19) 2 1 Overheads (14) 2 1 Total (excl.vat) 20 10 Signature (or fax indicating your agreement) : P. Martinez
FOR COMMISSION USE P 3 3 1 1 4 A2. ADMINISTRATIVE DETAILS Full coordinates of the partner (one page by partner ) Name :[ Vladesz (ADMINISTRATIVE OFFICIAL) First name :[ Krystyna Legal Name of the organization carrying out the research: [ Institute of Medical Research, departement [ of microbiology Street Name and n : [ Aleje Niepodl., 156 B Town: [ Warszawa Postal Code / Cedex : [ 00950 / [ P.O Box : [ Country code (6): [ PL Telephone number (country and area code) (11): [ +48 22 33 46 78 Telefax : [ +48 22 33 34 56 email: [ kvladesz@uni.mede.pl Name of the scientific partner for the proposed research (4) : Name :[ Prof. Pavlav First name :[ Jozef [ Institute of Medical research, departement of Microbiology [ Street Name and n : [ Aleje Niepodl., 156 B Town: [ Warszawa Postal Code / Cedex : [ 00950 / [ P.O Box : [ Country code (6): [ PL Telephone number (country and area code) (11): [ +48 22 33 47 89 Telefax : [ +48 22 33 45 67 email: [ Summary table of proposers costs: Cost category Total Cost (kecu) (7) Requested EC contribution (kecu) (8) Labour (13) Effort in manmonths 35 14 14 Av. monthly rate (ECU) 400 Travel & Subsistence (17) 6,5 6,5 Durable equipment (15) (please describe in the detailed proposal description B2) 9,5 9,5 Consumables (18) 6,5 6,5 External Assistance (16) Other Expenditures (19) 0,5 0,5 Overheads (14) 3 3 Total (excl.vat) 40 40 Signature (or fax indicating your agreement) : J. Pavlav
FOR COMMISSION USE P 4 3 1 1 4 A2. ADMINISTRATIVE DETAILS Full coordinates of the partner (one page by partner ) Name :[ Dudits (ADMINISTRATIVE OFFICIAL) First name :[ Daniel Legal Name of the organization carrying out the research: [ National Academy of Health [ Street Name and n : [ Sverzita Ter 889 Town: [ Budapest Postal Code / Cedex : [ 1374 / [ P.O Box : [ Country code (6): [ HU Telephone number (country and area code) (11): [ +36 1 987 654 3 Telefax : [ +36 1 987 654 9 email: [ ddudits@naac.health.hu Name of the scientific partner for the proposed research (4) : Name :[ Ramzo First name :[ Tamas [ National Academy of Health [ Street Name and n : [ Sverzita Ter 889 Town:[ Budapest Postal Code / Cedex : [ 1374 / [ P.O Box : [ Country code (6): [ HU Telephone number (country and area code) (11): [ +36 1 987 654 0 Telefax : [+36 1 987 654 9 email: [ Summary table of proposers costs: Cost category Total Cost (kecu) (7) Requested EC contribution (kecu) (8) Labour (13) Effort in manmonths 40 12 12 Av. monthly rate (ECU) 300 Travel & Subsistence (17) 4,3 4,3 Durable equipment (15) (please describe in the detailed proposal description B2) 8 8 Consumables (18) External Assistance (16) Other Expenditures (19) 3 3 Overheads (14) 2,7 2,7 Total (excl.vat) 30 30 Signature (or fax indicating your agreement) : T. Ramzo
FOR COMMISSION USE P 5 3 1 1 4 A2. ADMINISTRATIVE DETAILS Full coordinates of the partner (one page by partner ) Name :[ Venskautanis (ADMINISTRATIVE OFFICIAL) First name :[ Stanislovas Legal Name of the organization carrying out the research: [ Medical University of Kaunas Departement of Pathology Street Name and n : [ Zygimantu str. 45 Town: [ Vilnius Postal Code / Cedex : [ 2600 / [ P.O Box : [ Country code (6): [ LT Telephone number (country and area code) (11): [ +370 2 222 555 Telefax : [ +370 2 222 000 email: [ Name of the scientific partner for the proposed research (4) : Name :[ Bansevicius First name :[ Algis [ Medical University of Kaunas Departement of Pathology [ Street Name and n : [ Zygimantu str. 45 Town:[ Vilnius Postal Code / Cedex : [ 2600 / [ P.O Box : [ Country code (6): [ LT Telephone number (country and area code) (11): [ +370 2 222 111 Telefax : [ +370 2 222 000 email: [ Summary table of proposers costs: Cost category Total Cost (kecu) (7) Requested EC contribution (kecu) (8) Labour (13) Effort in manmonths 40 10 10 Av. monthly rate (ECU) 250 Travel & Subsistence (17) 5 5 Durable equipment (15) (please describe in the detailed proposal description B2) 4 4 Consumables (18) External Assistance (16) 3 3 Other Expenditures (19) 2 2 Overheads (14) 1 1 Total (excl.vat) 25 25 Signature (or fax indicating your agreement) : A. Bansevicius
FOR COMMISSION USE PART B : SCIENTIFIC AND TECHNICAL DESCRIPTION B1. SUMMARY DESCRIPTION OF THE PROPOSED ACTIVITY (shall not exceed 1 page) If the proposal is written in a language other than in English, a translation of the Title and Summary in the English language should be provided in addition. Title of the proposed activity : Objectives and summary of the proposed activity:
B2. DETAILED DESCRIPTION OF THE PROPOSED ACTIVITY To be drafted under the responsibility of the project Coordinator and must not exceed 10 pages. The description should be clear and concise, detailing the tasks necessary to achieve the required results. It should not include costs as these are covered in other sections. Reference to specific dates should be omitted. The time necessary to accomplish each task should be expressed in number of months or years from the commencement of the project. The description should be structured along the following tables JOINT RESEARCH PROJECT JOINT DEMONSTRATION PROJECT 1. Present state of knowledge in the proposed research field (one page) 1. Present state of knowledge in the proposed field of application (one page) 2. Objectives of the proposed research Description of the research objectives, use measurable (quantitative) terms as far as possible. 3. Significance of the proposed research cooperation Description of the contribution to fundamental or applied science; relationship to the underlying themes. Justify why the project should be financed and highlight the innovative research aspects. 4. Scientific and Technical description A thorough description of methodology to be used should be given as regards the general technical approach, experimental techniques, software, tools and equipment to be used. A workplan clearly describing the scientific input of each partner should be included. This input should be complementary and reflect effective cooperation. 5. Organization and management Description of how the action will be organised and managed, the relevant experience and the role of the coordinator. A timetable (with a bar chart diagram) describing the scheduling of tasks should be included. Describe the cooperation activities with reference to each participant and the method of financial transaction. 6. Expected results Indicate the results and achievements which are expected and mention the ways how the project activities and results will be disseminated, including foreseen seminars and publications 2. Objectives of the proposed demonstration project Description of the objectives of the demonstration project, use measurable (quantitative) terms as far as possible (Any research and development phase must be substantially completed before the proposal is presented). Describe technically and economically viable prospects of subsequent commercial exploitation of the relevant innovative technology or process. 3. Significance of the proposed demonstration project Description of the contribution to fundamental or applied science; relationship to the underlying themes; benefits expected if applications are delivered; innovation it represents, dissemination, etc. 4. Scientific and Technical description A thorough description of methodology to be used should be given as regards the general technical approach, experimental techniques, software, tools and equipment to be used. All the main characteristics of demonstration projects in the field of energy (i.e. nominal power, temperature,pressure, flow rates, operating hours per year, etc...) as well as the site of installation should be described. A workplan clearly describing the tasks of proposer should be included. These tasks should be complementary and reflect effective cooperation. A timetable (including a bar chart diagram) describing the scheduling of tasks should also be included. 5. Organization and management Description of how the action will be organised and managed, the relevant experience and the role of the coordinator, the method of management, cooperation with reference to each participants, financial transaction, etc. 6. Expected results Achievements, prospects for replication, publications, seminars,etc.
CONCERTED ACTIONS ACCOMPANYING MEASURES 1. Present state of knowledge in the proposed research field (one page) 1. General description of the research field/actions (one page) 2. Objectives of the proposed research General description of the research objectives 2. Objectives of the proposed Action/Measure 3. Significance of the proposed research cooperation Description of the benefit and added value to establish the relation between ongoing research 3. Significance of the proposed Action/Measure Justify why the project should be financed. Describe the type of action and indicate the target group 4. Scientific and Technical description A general description of the implementation of the action 4. Scientific and Technical description A workplan clearly describing the scientific input of each partner should be included 5. Organization and management Description of how the action will be organised and managed, the relevant experience and the role of the coordinator. Describe the of cooperation activities with reference to each participant and the method of financial transaction 5. Organization and management Description of how the action will be organised and managed, the relevant experience and the role of the coordinator. A timetable with a bar chart diagram describing the scheduling of tasks should be included 6. Expected results Indicate the results and achievements which are expected and mention the ways how the project activities and results will be disseminated, including foreseen seminars and publications 6. Expected results Indicate the results and achievements which are expected and mention the ways how the results of the action will be disseminated KIT (Keep in Touch) The reference number of the related Joint Research Project to which the proposal is a Keep in Touch action should be given on the first page of the project description PART C : INFORMATION ABOUT THE PROPOSERS To be completed by each participant, starting with N 1 the coordinator, then N 's 2, 3, 4, etc. Each participant (including the coordinator) must include: 1. A brief Curriculum Vitae of the principal scientific staff involved in the proposal. 2. A list of their recent publications and patents in the field of proposed research. 3. A brief profile of the proposer's organization.