Iraq Biological Security Grant Competition Project Proposal P a g e 1 A. GENERAL PROJECT INFORMATION PROJECT INFORMATION Project Title (Not more than 100 characters) Total Amount Requested ($20,000 min. /$100,000 USD max.) Project Type (more than one box may be selected) APPLICANT & INSTITUTE INFORMATION Full Name (Last, First, Middle, as it appears in passport): Projected Length of Project (Not to exceed 12 Months) Laboratory design Repairs or maintenance of laboratory equipment Simple upgrades to laboratory Other Name of Institution: Position/Title: Work Phone Number: Cell Phone Number: Highest Degree Earned: Name of Department: Field of Research/Work: Email address: Field of Degree: Gender: Male Female Date of Birth (Month/Day/Year): Have you or your institution been a grant recipient or participated in an event/activity with CRDF Global before? Yes No If yes, please explain: Do you have your Institute s Letter of Support for this project? Yes Institute Address: Name of Head of Institute: Head of Institute s E-mail: No Are you partnering with another institute (unaffiliated with your institute) for this project? Yes Do you have your partnering institute s Letter of Support for this project? Yes PROJECT TEAM MEMBER INFORMATION No No Total number of project members, including applicant: Total number of project members, including applicant, receiving honorarium (only two permitted per proposal):
P a g e 2 B. WORKSHOP/TRAINING SKILLS AND COMPETENCIES Please complete this section ONLY IF your proposal involves a workshop and/or training. TRAINEE EXPERIENCE Please describe, in detail, any biosafety and/or biosecurity trainings you have received within the past two years in the space provided below. Please include the following information in your description: Name of the training(s); Date of the training(s); Host of/organization that led the training(s); and Location of the training(s). If you have not completed any biosafety and/or biosecurity trainings within the past two years, please leave this section blank. TRAINER EXPERIENCE How many workshops and/or trainings have you conducted as a lead trainer? 0 Up to five Up to 10 More than 10 How many workshops and/or trainings have you conducted as a supporting trainer, or member of a training team on which you were not the primary trainer? 0 Up to five Up to 10 More than 10 Please describe, in detail, your experience as a trainer in the field of biosafety and/or biosecurity in the space provided below. Please include the following information in your description: Names of the organizations for which you have served as a trainer; The audience(s) (academia, industry, government, etc.) which you trained; and The specific topics you covered as a trainer. If you have never served as a trainer in the field of biosafety and/or biosecurity, please leave this section blank.
C. INSTITUTION BIOGRAPHICAL DATA FORM (Check all that apply) P a g e 3 Which of the following best describes your organization? Academic Clinical Laboratory (Medical or Veterinary) Government Diagnostic Laboratory (Medical or Veterinary) Contract Research Veterinary Hospital Pharmaceutical/Biotechnology University Veterinary Center Hospital or University Medical Center Other Which of the following best characterizes the stage of your laboratory s work with infectious agents or toxins? Basic Research Disease Surveillance Clinical/Diagnostic Drug Discovery &/or Development Translational Other Where does your facility receive funding to conduct your bioscience work? Local, Regional or National Government Non-medical Corporation Pharmaceutical, Biotechnological or Diagnostic Royalties or Sales International Donors Other Company Private Foundation or Charity Which Biosafety levels (as described in the WHO Laboratory Biosafety Manual) best categorize the laboratories at your institution? Biosafety Level 1 (BSL1 or P1) Biosafety Level 2 (BSL2 or P2) Biosafety Level 3 (BSL3 or P3) Biosafety Level 4 (BSL4 or P4) Not Applicable Total number of staff members in your organization: Total number of above individuals who have direct access to the laboratory: Do contractors work inside your laboratories: Yes No Do visitors have access to your laboratories: Yes No Access Level of the laboratories: Open Access Limited Access Restricted Access List below all the pathogens and toxins used or stored at the institution. BACTERIA: VIRUSES: TOXINS: OTHERS:
P a g e 4 D. PROJECT PROPOSAL DETAILS Project Description: Clearly and concisely describe the proposed project and explain what the project will achieve. Project Impact on Biosafety, Biosecurity, and Biorisk Management: Clearly and concisely explain how the proposed project will improve biosafety, biosecurity, and biorisk management at your institution. Expected Outcome and Sustainability Potential: Clearly and concisely explain who will benefit from the project and how they will benefit. Explain who will assume financial responsibility (if applicable) after the three month completion deadline, or other ways in which the project outcomes will be sustainable. Supporting Documentation: Include any other justification in support of project proposal if relevant, such as equipment information, training agenda, etc. If possible copy and paste into this document.
P a g e 5 E. PROPOSED TIMELINE (This project MUST be completed within a 12 month timeframe) # TASK DESCRIPTION List steps necessary to complete your project and put an X to show in which project month each step will be accomplished EX Example Task: Finalize specification for necessary equipment and confirm validity of original quotes MONTHS 1-4 5-8 9-12 X EX Example Task: Procure and install necessary equipment and conduct testing to ensure proper functioning X
P a g e 6 F. Principal Investigator Acknowledgement Signature: Your signature below indicates that you have properly read through all documentation provided, including the project announcement, application file, budget file, FAQ, and proposal guidelines (if applicable). In addition, your signature also indicates that you have watched the Biological Security Grants Competition Instructional Video. Full Name (First, Last) Date Position Title Laboratory/Institution Name