2024 NKF Health Equity Community Engagement Award

Page 1

***STOP!***

Only use this form to start a NEW application.

If you've already started an application, use the link in the top right-hand corner to resume your application. Click "Next Page" to find and resume where you left off.

Welcome!

Please review the Instructions to Applicants for National Kidney Foundation Health Equity Grants before completing this application.

All applications and supplementary materials are due by February 12, 2024.

Page 3

About Applicant

Applicant's Highest Degree:

Citizenship or Visa Status

Prior and/or Current NKF Support (Individual or Program)

YesNo

Present Mailing Address

Address Line 1

Address Line 2

City

State/Province

Postal Code

Country

Is your Permanent Address the same as your Present Address?

YesNo

Permanent Mailing Address

Address Line 1

Address Line 2

City

State/Province

Postal Code

Country

Phone and Fax

Work Phone

Home Phone

Permanent Phone

Fax Number

Page 4

Sponsoring Institution

Name of Proposed Sponsoring Institution:

Address Line 1

Address Line 2

City

State/Province

Postal Code

Country

Department, Service, Laboratory, or Equivalent:

Major Subdivision:

Entity Tax Identification Number:

Other Personnel

Other Professional Personnel Associated with the Project (List name, degree and position of each professional associated with the project and indicate their capacity, e.g. Collaborating Investigator, Research Assistant, etc.)

Documentation of Collaborative Arrangements

Upload letters from consultants/partners indicating their willingness to assist in the pursuit of this project and any conditions on such assistance, if applicable. e.g. community-based partner who will be available to consult with regard to evaluation of data collected.

*All uploaded files must be in either PDF or Microsoft Word format

Click on the "Choose Files" button to find the appropriate file(s) on your computer. Clicking "Open" will upload the file(s). Your file will be automatically uploaded.

How many Letters do you need to upload?

Letter 1

Letter 2

Letter 3

Letter 4

Letter 5

Letter 6

Letter 7

Letter 8

Letter 9

Letter 10

Page 5

Assurances

(Upload copies of relevant documents below.)

Human Subjects?

YesNo

Date Approved:

Please check here if date is still pending

Upload Relevant Documents (optional)

Signatures

The indivuduals signing below attest that:

Research funded pursuant to this application will be conducted as described herein
Institutional resources will be made available, as specified, to pursue this investigation. They agree to follow the terms and comply with the policies for the research funding mechanism for which funding is sought.

Note: By signing this application electronically, I certify the information provided is accurate. I understand that an electronic signature has the same effect and can be enforced in the same way as a written signature.

Applicant's Signature

Date

Name of Fiscal Officer:

First Name

Last Name

Title of Fiscal Officer:

Page 6

Research Proposal

Attach pages describing research proposal in the format described in the respective Instructions to Applicants.

Please observe the page limitations for each section of the research proposal as described in the Instructions to Applicants.

*All uploaded files must be in either PDF or Microsoft Word format

Research Proposal Upload

Letters of Support (Optional)

Attach three (3) letter of recommendation from health partners, supervisors, etc.

*All uploaded files must be in either PDF or Microsoft Word format

Letter 1

Letter 2

Letter 3

Page 7

Applicant Biosketch

Applicant's Employment/Training

(after college) in chronological order

Activity/Occupation 1

Activity/Occupation

From:

Month

Year

To:

Month

Year

Field

Institution/Company

Supervisor/Employer

Activity/Occupation 2

Activity/Occupation

From:

Month

Year

To:

Month

Year

Field

Institution/Company

Supervisor/Employer

Activity/Occupation 3

Activity/Occupation

From:

Month

Year

To:

Month

Year

Field

Institution/Company

Supervisor/Employer

Prior or Current Research Support

List type (individual and/or institutional), dates, and grant or award numbers for funding that is available to support your research. Explain any budgetary and/or topic overlap with the proposed NKF funding and the relationship between the project proposed in this application and any other current research awards.

Academic and Professional Honors

Include all scholarships, traineeships, fellowships, and development awards. Indicate source of awards (NSF, Woodrow Wilson, etc.), dates, and grant or award numbers. List current professional societies, if applicable.

Applications for Concurrent Support

Is this an application for concurrent support?

YesNo

List all pending support (training, research, supplies, travel, etc.) that would run concurrently with the period covered by this application whether or not you are the Principal Investigator. Include the type, date, source and amount.

Pending Support 1

Type

Source

Date From

Date To

Amount

Pending Support 2

Type

Source

Date From

Date To

Amount

Pending Support 3

Type

Source

Date From

Date To

Amount

Pending Support 4

Type

Source

Date From

Date To

Amount

Pending Support 5

Type

Source

Date From

Date To

Amount

Explain any potential budgetary overlap with the proposed NKF funding and the relationship between the project proposed and any other application for research support:

(Optional) Upload Biosketch

Page 8

Research Experience

Summary

Publications (published, accepted, submitted, or in preparation)

Time Commitment

Approximate percentage of time spent on this project

%

Page 9

Lay Summary (A brief (150 words) description of the research that the applicant proposes to undertake should be written as a summary for a lay audience. The summary should include a brief discussion of the proposed project and an indication of its potential impact in preventing, reducing, or eliminating kidney health disparities and advancing health equity in local communities or populations at risk for and overburdened with kidney diseases Scientific jargon, abbreviations and complex discussions should be avoided.)

Page 10

Signatures

Applicant Signature

Note: By signing this application electronically, I certify the information provided is accurate. I understand that an electronic signature has the same effect and can be enforced in the same way as a written signature.

Date

FINALIZE

Finalize Application

Acute Kidney Injury	Cardiology	CKD
Conservation Mgmt	Diabetes	Diabetes Educator
Dialysis	Electrolytes	Electrolytes
Endocrinology	Family Medicine	Gastroenterology
Geriatrics	Glomerulonephritis	Hemodialysis
Home Dialysis	Hypertension	Infectious Disease
Internal Medicine	Living Donation	Mineral Bone
Nephrology	OB/GYN	Other
Nutrition	Pediatric	Peritoneal Dialysis
Polycystic Kidney	Pre-Dialysis Consultation	Pre-ESRD
Primary Care	Radiology	Research