Pathology Research and Innovation Fund

Fields denoted by an asterisk (*) are required.

Title of Project:
Applicant's Email:
I am applying for

I am applying for Stream 1 Stream 2 Stream 3
Principal Investigator(s) - Resident/Fellow:
Principal Investigator(s) - Pathologist/Mentor:
Principal Investigator(s) - Pathologist:
Title of Publication:
Co-Investigators
List of Authors:
I confirm that I am the Principal Author or Corresponding Author:

I confirm that I am the Principal Author or Corresponding Author: I Confirm
Location of Research Study:
Period of Support (up to 2 years; renewable for 1 year if approved):
Total Budget Requested:
Has this project been submitted for review by the Western University Health Sciences Research Ethics Board?

Has this project been submitted for review by the Western University Health Sciences Research Ethics Board? No, not applicable (No human subjects) Yes, approved (copy of approval notice attached) Yes, approval pending Not yet submitted
Please attach a copy of approval notice

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Under the following subtitles, please provide a brief outline of the project on this page.
Rationale of the Project:
The methodology to be used:
The expected results:
Personnel involved in project:
Please attach any additional information:

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Detailed budget:

If any of these categories do not apply, please type N/A.
Undergraduate Student salary support (include 4% vacation pay, 14% benefits)
Is this for Graduate Student/Research Fellowship support?

Is this for Graduate Student/Research Fellowship support? Yes No
Graduate Student/Research Fellowship support budget
For a graduate student support, please attach curriculum vitae and the academic record of the student and proof of acceptance in the Department of Pathology and Laboratory Medicine Graduate Program, Western University.

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Consumables/Supplies
Publication fees (estimate)
Are you requesting a budget for tissue samples?

Are you requesting a budget for tissue samples? Yes No
Tissue samples budget
Specific details must be provided including a copy of the budget for lab work provided by Patricia Jarosz or other quotes as appropriate.

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Other
Please attach a copy of the publication:

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Please attach a copy of the payment receipt and proof of currency conversion (if applicable)

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TOTAL
Total publication fee (in CDN):
Total budget requested (up to $5,000 CDN):

Pathology Research and Innovation Fund

Pathology Research and Innovation Fund

Under the following subtitles, please provide a brief outline of the project on this page.

Detailed budget: