[ FORM 1 ]Application and Research Proposal

Application and Research Proposal for
Global Collaborative Research Project FY2024(☐ New / ☐ Renewal : Project No. __________ )To: Director of Brain Research Institute, Niigata University
APPLICANT (PRINCIPAL INVESTIGATOR)
Full Name

Title (please tick)

Position

Research Areas

Affiliation

Full Postal(Department, Faculty,University / Institution)☐Professor ☐Dr. ☐Mr. ☐Ms. ☐Mx.

Address

EmailTelephone

BRI COLLABORATOR
Full NameBRI Department

Position

CHOOSE FROM HERE

Applicant (PI) has obtained the approval of the BRI collaborator for this proposal. (mandatory)☐ Yes

RESEARCH PROPOSAL
1.

PROJECT TITLE(English)(Japanese)
2.

RESEARCH COLLABORATION CATEGORY☐ Neuropathological specimens of brain disease☐ Genome analysis on brain disease☐ Production and analysis on animal resources of brain disease☐ Translational research focused on the development of non-invasive imaging analysis technique☐ Open research utilizing BRI resources
3.

SUMMERY OF RESEARCH

Global Collaborative Research Project for FY2024, Brain Research Institute, Niigata University

Page 1 of 6

[ FORM 1 ]Application and Research Proposal☐ 1. Fixed samples of humans☐ 2. Frozen specimens of human brain
Resource / Facility Use
If any of 1. through 5. are to be
performed at Niigata University,
review and approval by NU isrequired. Please consult withBRI collaborator for furtherdetails.

☐ 3. Human DNA and RNA☐ 4. Animal experiment →☐ Tick if experiments will NOT be performed at Niigata University.
☐ 5. Recombinant DNA animal models →☐ Tick if experiments will NOT be performed atNiigata University.
☐ 6. Radioisotope☐ 7. Others)(please specify.
4.

ETHICS: Please tick if planning to conduct relevant experimentation.

I will comply with a code of ethics at the experiment facility☐ Yes, I will.

5.

RESEARCH PURPOSE: State the research goals and objectives (100 – 150 words).

6.

RESEARCH PLAN: Describe succinctly the design of the study and the methods. Create an appendix if necessary.

Global Collaborative Research Project for FY2024, Brain Research Institute, Niigata University

Page 2 of 6

[ FORM 1 ]7.

Application and Research Proposal

PREVIOUS RESEARCH WORK RELEVANT TO THE PROPOSED RESEARCH: Explain clearly the preceding works
related to the given project. Create an appendix if necessary.

Global Collaborative Research Project for FY2024, Brain Research Institute, Niigata University

Page 3 of 6

[ FORM 1 ]8.

Application and Research Proposal

OTHER RESEARCH WORK TO DATE: Provide full details of the publications for the last five (5) years. (author(s), title ofarticle, journal and year, volume, pages) Create an appendix if necessary.

Global Collaborative Research Project for FY2024, Brain Research Institute, Niigata University

Page 4 of 6

[ FORM 1 ]9.

Application and Research Proposal

RESEARCH MEMBERS: List ALL members who participate in this research. Create an appendix if necessary.

PRINCIPAL INVESTIGATOR
Full Name
Gender☐ Male☐ Female

Date of Birth☐ Other(DD/MM/YYYY)

Role in this Research
BRI COLLABORATOR
Full Name
Gender☐ Male☐ Female

Date of Birth☐ Other(DD/MM/YYYY)

Role in this Research
CO-INVESTIGATOR 1
Full Name
Position
Gender☐ Male☐ Female

Date of Birth☐ Other

Affiliation(Department, Faculty,University / Institution)(DD/MM/YYYY)

Role in this Research
Telephone

Email

CO-INVESTIGATOR 2
Full Name
Position
Gender☐ Male☐ Female

Date of Birth☐ Other

Affiliation(Department, Faculty,University / Institution)(DD/MM/YYYY)

Role in this ResearchTelephone

Email

CO-INVESTIGATOR 3
Full Name
Position
Gender☐ Male

Date of Birth☐ Female☐ OtherAffiliation(Department, Faculty,University / Institution)(DD/MM/YYYY)

Role in this Research
Telephone

Email*Providing gender and DOB details are necessary for the report to the Ministry of Education (MEXT) in relation to promoting the activities of young
and female researchers.

Global Collaborative Research Project for FY2024, Brain Research Institute, Niigata University

Page 5 of 6

[ FORM 1 ]Application and Research Proposal

10. ESTIMATED TRAVEL EXPENSES: lodging, transport and meals to BRI (up to 500,000 JPY).
Traveler Name

Destination

Brain Research Institute, Niigata University

Purpose
PeriodStart on(DD/MM/YYYY)

Durationdays(tentative)

End on(DD/MM/YYYY)

Estimated Expenses

JPY

Traveler Name

Destination

Brain Research Institute, Niigata University

Purpose
PeriodStart on

(DD/MM/YYYY)

Durationdays(tentative)

End on(DD/MM/YYYY)

Estimated Expenses

JPY

Total Estimated Expenses

JPY

11. POSSIBILITY OF SELF-FUNDED RESEARCH: Please tick if YES.
When this application is not successful for acquiring the BRI research funding, I (applicant) still wish to carry outthe proposed research with my own financial resources.

☐ Yes

I certify that all information in this application is true to the best of my knowledge.

Date
Applicant’s Signature

DateChecklist: Please make sure to attach the following:☐ Curriculum Vitae of PI (applicant) *Not applicable for those who have already submitted in the previous year.
☐ Progress Report (Form 2) *Renewal projects only.

Global Collaborative Research Project for FY2024, Brain Research Institute, Niigata University

Page 6 of 6