[Cover Page]

Serial no:(to be filled up by office)Title:

Principal Investigator’s Name:
Mobile No:
E-mail Address:
Institution:

Annexure-1

Grant Application Form
Title:
Part-A: General information
1. Name of Principal Investigator(s) with designation, address, mail ID, mobile no:
a.
b.
c.
d.
e.

Name:
Designation:
Address:
E-mail ID:
Mobile number:

2. Name of the organization (if submitted on behalf):
3. Place of study:
4. Proposal related information:a. Title:b. List of Co-investigator(s)/name of the team members:
Co-PI:Co-I:

c. Approval/forwarding of the head of the department/institute:d. Area of research: (Which area of research will be covered according to theadvertisement)
5. Duration of the study:
6. Total amount of budget (in taka):

Part-B: Information about the investigators and or organization
Details about the Principal Investigator (PI)
a.
b.
c.
d.
e.
f.

Name:
Present address:
Current Affiliation:
Email:
Mobile number:
Educational qualification (From recent to graduation):
Degree/Fellowship

Institution

Yearg. Previous research experience (Can be attached with CV):h. List of publication including up-to-date citation score and h-index (Can be attached withCV):
i. A copy of detail CV (not more than 3 page):
Details about the Co-PI/ Co-investigators (please use same proforma for every Co-PI as per
required number)
a.
b.
c.
d.
e.
f.

Name:
Present address:
Current Affiliation:
Email:
Mobile number:
Educational qualification (From recent to graduation):
Degree/Fellowship

InstitutionYearg. Previous research experience (Can be attached with CV):h. List of publication including up-to-date citation score and h-index (Can be attached withCV):
i. A copy of detail CV (not more than 1 page):
Other research assistants (please provide a CV not more than 1 page)a. PhD/MPhil studentsb. Laboratory staff
c. Others (brief description of the organization if submitted through an organization)

Part-C Executive Summary(Do not start writing from this page and start writing from next page)Part-C: Executive summary (not exceeding two pages) and should cover thefollowings
Title:
1. Aims:
2. General objective:
3. Specific objectives:
4. Rationale:
5. Methodology (Brief) (This section must include study duration):
6. Ethical clearance:
7. Impact of the study in future research:
8. Impact of the study at national level:
9. Total amount of budget (in taka):

Part-D Technical Information(Do not start writing from this page and start writing from next page)Part-D: Technical Information
Title:

1. Background of the study:
2. Rationale of the study:
3. Literature review:
Author, year

Major findings

4. Objectives and outcomes:
This section should answer the question “why is this project needed at this time, at this place?” List at least threemajor objectives and their related outcomes. Objectives should be SMART (Specific, Achievable, Realistic and Timebound) and include as relevant research and capacity building objectives.

Objectives (in SMART format)

Expected Outcome (the impact or charge
in the field that the project will havecontributed to)

5. Key deliverables and success indicators for the proposal:
List at least four deliverables produced by this project (e.g. research evidence, trained scientist/capacity
development, new approach, policy briefs, network etc.)
For each deliverable, list one or two milestone and timeline of achievement. Add as many rows as necessary.

Deliverable list
Deliverable 1:
Milestone 1.1:
Milestone 1.2:
Success indicator 1
Deliverable 2:
Milestone 2.1:
Milestone 2.2:
Success indicator 2

Deadline (by)

6. Methodology:
Describe the design of the study and methodology in detail to enable assessment of how they will contribute towards
achievement of the stated objectives and to permit proper appraisal of the budget. It should also include data
management plan, statistical analysis, quality assurance and dissemination of results.

7. How this project will help to achieve sustainable development goals?
8. Gantt Chart:9. References: (Vancouver’s or Harvard style to be followed)

Part-E Budget Related Information(Do not start writing from this page and start writing from next page)Part-E: Budget related information
Proposal budget must fill-up the following itemized template of budget according to year and sub head total assummary along with the detailed budget.

Item
Human resource including
contractual service (notexceeding 20% of the totalbudget)
Workshop/ training
related cost
Field Expenses
Laboratory Cost
Supplies andMaterials/Consumables
Patient Cost
Travel Cost
Office Stationery
Data ProcessingPrinting and Reproduction(including article
processing charge)
Minor equipment
Administrative Overhead:(Max. 10% if supporttaken)
Miscellaneous(Not exceeding 20 % ofthe total budget)
Total (year wise)Grand total

Price (in BDT)

Year 1

Year 2

Part-F: Information related to fund from other source(s):1. Did the proposal being submitted/ received any funding from other source(s)?
□ Yes

□ No

2. If YES, please answer the following questions:A. Source of fund/ funding agency (In details):
B. Year of funding (with duration):
C. Amount of fund received (in BDT):
D. What was the title of the proposal?
E. Have you completed the project? □ Yes□ No

F. If NO, please explain why it was not completed?
G. If NO, please mention the expected date of completion:
H. If Yes, have you submitted the project report?
I. Was the result published in any local or international journal? □ Yes
J. If YES, Name of the journal including title and volume of the paper.

□ No

Part-G: Declaration
I / We do hereby declare that,a) This proposal or part of the proposal has not been submitted to anywhere else for any
research grant/ funding.
b) The proposed proposal is not a copy of or duplication of any completed or ongoing
research/ project/work.
c) We do hereby declare that we agree to the terms and condition declared by the grantauthority.
d) In absence of the principal investigator (either not completing the research or leaving theinstitution), Co- PI (s) shall take the responsibility to complete the research.
e) In case of institution/ organization: All the facilities available at the institution/organization can be used to carry out the research.

Name of the principal
investigator:

Name of the Co-Pricipal
investigator (s):Name of the Co-investigator(s):

Sign:

Sign:

Sign:

Official seal

Official seal

Official seal:

Mobile no:

Mobile no:

Mobile no:

Date:

Date:

Date:

[Sample Envelop]

FromToTitle of the Protocol:

Principal Investigator’s Name:

Mobile No.

:

Subject of Research:

Short Title of the Protocol:

President, Health Science Research
Development Fund
Room No. 913, 8th Floor, National
Institute of Neuroscience andHospital, Agargaon, Dhaka