Medical Research Grant Request

Medical Research Grant Request

Instructions:

All fields must be completed. If a field is not completed, please note the reason.

If it’s not applicable, please indicate N/A.

This form covers the two different ways Akebia may engage in external research:

Investigator Initiated Research: Unsolicited and independent research initiated by an external sponsor
Collaborative Research: Research conducted in collaboration between Akebia and an external sponsor

Principal Investigator Contact Information

Name*

Title*

Address 1*

Address 2*

City*

State*

Zip*

Country*

Phone*

Phone

Fax*

Phone

Email*

Sub-Investigator Contact Information

Name*

Title*

Phone*

Phone

Fax*

Phone

Email*

Study Coordinator Contact Information

Name*

Title*

Phone*

Phone

Fax*

Phone

Email*

Institution Contact Information

Name*

Address 1*

Address 2*

City*

State*

Zip*

Phone*

Phone

Fax*

Phone

Website*

Legal/Contracts Contact Information

Name*

Title*

Phone*

Phone

Fax*

Phone

Email*

Study Information

Proposed Study Title*

Indication*

Primary Product*

Phase*

Study Population*

Sample Size*

Background and Study Rationale*

Provide background on unanswered question(s) the study is attempting to answer

Study Objectives*

List the objectives and endpoints to correspond directly with the listed Hypotheses

Hypothesis*

List the Hypotheses in order of priority

Study Design/Research Plan*

Provide a concise overview stating the type of experimental design

Treatment Plan*

Describe the dosing regimen, administration, and schedule

Inclusion and Exclusion Criteria*

Define the target population and include demographic and clinical characteristics for (in)eligibility

Laboratory Procedures/Evaluations*

List all laboratory tests to be done (i.e. biochemistry, biomarkers, etc.)

Statistical Plans*

Include justification for sample size and primary hypothesis testing

Direct Study Costs

Please enumerate.

Subject-Related Costs*

Study-Related Personnel Costs*

Diagnostic Fees*

Data Management Fees*

Other*

Indirect Study Costs

Please enumerate.

IRB Fee*

Equipment/Supply Fee*

Animal-Related Costs*

Other-Indirect*

Total Amount*

Send me a copy of my responses

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