InBev-BAILLET LATOUR GRANTS FOR MEDICAL RESEARCH 2016 : Infectious Diseases APPLICATION FORM

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1 InBev-BAILLET LATOUR GRANTS FOR MEDICAL RESEARCH 2016 : Infectious Diseases APPLICATION FORM This file must be filled in electronically in English (font Century Gothic, font size 10, not exceeding the space allowed) and sent by to the administrative assistant of the IBL Scientific Committee at no later than June 30, 2015 (this is a strict deadline). No attachments are allowed. Incomplete files will be rejected outright. A. PROJECT TITLE (max 240 characters, excluding blanks) B. PRINCIPAL INVESTIGATOR (PI) Last name (family name), First name (given name) Date of birth (dd/mm/yyyy) Nationality Country of birth Gender (M/F) Title (MD, PhD,...) Date of award of PhD degree (dd/mm/yyyy) Present academic position Your salary to conduct this research must be secured until June 30, 2021: define here with which status or contract(s). C. CURRENT WORK ADDRESS address Department Institution Postal address Phone number

2 2 D. BELGIAN INSTITUTION WHERE WORK WILL BE PERFORMED Check here and do NOT complete D.1 if same as current address D.1 Department Institution Postal address Phone number D.2 Grant funds manager (physical person or accounting department) Full legal address Account number (IBAN + BIC)

3 3 E. CV OF THE PI Academic degrees : Diplomas (including title and supervisor of Ph.D. thesis) with date of award and granting institution Employments (in chronological order) Use as many boxes as necessary. If you are an Independent Researcher, please note IR under Name of head Institution and location Position (including source of salary for research appointments) Name of head From (dd/mm/yyyy) To (dd/mm/yyyy) Please detail below any career breaks

4 4 List here any other data (professional memberships, honours, prizes) relevant for the PI s scientific evaluation F. PUBLICATIONS OF THE PI Bibliometric indicators for the PI Citation Database used ISI Web of knowledge Scopus H index Total number of citations Number of citations for the PI s most cited original research article Reference of the PI s most cited original research article Most important peer-reviewed original research articles of the PI (max 5) Give all authors with your name and the name of members of your team in capital letters. Indicate full title, impact factor (IF) and number of citations References (with inclusive pages) IF N of cit. 1 2

5 Other peer-reviewed publications of the PI as first or last author List them in chronological order. Do not include abstracts, publications submitted or in preparation. Indicate all authors, full title, impact factor (IF) and number of citations References (with inclusive pages) IF N of cit.

6 6 Other peer-reviewed publications of the PI List them in chronological order. Do not include abstracts, publications submitted or in preparation. Indicate all authors, full title, impact factor (IF) and number of citations References (with inclusive pages) IF N of cit. Patents by the PI List filed or published patent applications or granted patents (with date of granting) where the PI is an inventor. Indicate the inventors, title, priority date, filing number and publication number if applicable Filed/published patent applications : Granted patents :

7 7 G. COMPOSITION OF THE PI s TEAM directly reporting to the PI on June 30, 2015 Number Name(s) Permanent position(s) Including the PI Postdoctoral fellow(s) Ph.D. student(s) Technician(s) Not applicable H. DOCTORAL THESES SUPERVISED BY THE PI Name (first, last) of the student Title of thesis Date of award I. HEADS OF COLLABORATING TEAMS in Belgium or abroad (optional) Name (first, last) Institution Country

8 8 J. FUNDS AVAILABLE TO THE PI List active or approved grants (Use as many boxes as necessary) Funding agency Project title Name(s) of the beneficiary(ies) and rôle (PI or other) Amount available to PI ( /year) Ending date (dd/mm/yyyy) If there is a scientific or budgetary overlap with this proposed research project, please describe :

9 9 K. SCIENTIFIC ACHIEVEMENTS TO DATE (For references in the text give name of first author and year of publication of the corresponding papers listed in Section F) In the field of Infectious Diseases (max 1 page) Skip if redundant with Section L

10 In other fields (max 1 page) Skip if irrelevant 10

11 11 L. PROPOSED RESEARCH PROJECT (For references, see end of this section) Abstract (max 1800 characters, excluding blanks)

12 Preliminary data (max 1 page) State the starting hypotheses and supporting preliminary evidence 12

13 13 Research project (max 3 pages ; additional pages will not be taken into account) State the objectives, the originality and possible developments of the project. The research project is for 5 years. If awarded, funding is for years pending evaluation at mid-term

14 Methodology (max 1 page) 14

15 15 Feasibility and alternatives (max 1 page) Discuss the limitations and alternatives for your proposed project

16 References cited (by numbers) in the research project Provide here a single list of references (with full titles) for the citations in all the of Section L 16

17 17 M. EXCLUDED REFEREES Referees are non-belgian scientists working abroad ; they must sign Non Disclosure and Nonconflict of Interest Agreements. The Applicant may indicate below excluded referees. (Use as many boxes as necessary) Excluded referees (optional) Name (first, last) address Institution I hereby confirm that all the above data and information, including the current and future status of the PI as defined in the last frame of Section B, are correct Date : Signature of the Rector of the host Institution Signature of the PI February 9, 2015

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