Accelerate PhD Fellowship Proposal Application2015

Instructions:

Please refer to: https://www.mitacs.ca/en/programs/accelerate/accelerate-phd-fellowship

Send your draft proposal to your Mitacs Business Development Representative or to accelerate@mitacs.ca prior to obtaining all signatures and submitting minimum 7 days prior to the deadline date.

The proposal should be written and submitted no later than 1p.m. PDT on May 6, 2015, via email to accelerate@mitacs.ca.

Partner funds can be sent directly to Mitacs prior to approval to expedite the process or upon approval.

If applicable, conflict of Interest declarations must be received by Mitacs BEFORE submitting your application (see section 4.1/4.3).

Please note:

If required, your Mitacs Business Development Representative can assist you with:

o Identifying your Office of Research Services (ORS) representative.

o Facilitating non-disclosure agreements or intellectual property arrangements.

o Assessing the eligibility and completeness of the proposed research.

Application checklist:

A COMPLETE internship application package must include the following *:

□ The Accelerate PhD Fellowship proposal application completed and signed by all parties. The memorandum with signatures must be submitted as a scanned PDF file.

□ List of six external expert, arms-length reviewers and their contact information

□ PhD Intern CV (a CV template is available on the Mitacs website)

□ Any supplementary documents (as applicable)

□ Ontario applicants (interns only): completed and signed Appendix A, Ontario Notice of Collection of Personal Information and Consent

□ Quebec applicants (supervisor only): completed and signed Appendix B, Fonds de recherche du Québec - Nature et technologies Commitment and Consent

* An incomplete application will result in a delay in the internship evaluation process.

For more information, contact a Business Development representative.Accelerate PhD Fellowship – Proposal Application – March 2015 Page 1

1. Research Proposal Summary

1.1. Title of project:

1.2. Type of project: PhD Fellowship – Call for Proposals Spring 2015

1.3. Keywords to identify reviewers:(min. three, max. 10 specific keywords; 50% technically related, 50% discipline-related)

1.4. Academic discipline: Select Discipline

1.5. Project priority sectors: Please rank up to three top priority sector(s) of your project.

Select 1st Priority Sector Select 2nd Priority Sector Select 3rd Priority Sector

1.6. Internship purpose: Please indicate the advancement you want to achieve with this internship.

☐ Creation of new materials, devices, or products☐ Creation of new processes or services☐ Improvement of existing materials, devices, or products☐ Improvement of existing processes or services

1.7. List of participants:Supervisor(s) Department University

Partner organization(s) Contact name at partner organization

Location of organization(Province)

Partner Legal Status

Select Legal StatusSelect Legal Status

1.8. Proposed work plan for PhD fellowship: Please outline the work plan by objective, theme, or subproject, as applicable. Right-click on the table and select “Worksheet Object.” Select “Edit” to edit within the proposal template

or “Open” to open in Excel.

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 2

Intern Name YearWork plan (month )

1 2 3

Example Jane Do PhD 1 Objective 1

Degree (PhD)

2.0. Description of Proposed Research

2.1. Project title:

2.2. Research Abstract (150 words): The abstract differs from the public project overview, as it may be used to recruit reviewers so it must clearly summarize the research proposed. Please include 1-2 sentences describing each topic: Background and problem, objectives, methodology, expected results and relevance for the intern(s) and partner organization(s).

2.3. Background and review of relevant prior work (minimum 500 words):

2.4. General objective of the research project broken down into sub-objectives, activities, themes, or subprojects, as applicable:

2.5. Details of PhD proposed research:a. Specific objectives of the internship. Clearly state your [sub-] objectives so reviewers

can assess if they are achievable.b. Methodologies. Provide enough detail so reviewers can determine if the proposed

methodology is appropriate and sufficient to achieve the [sub-] objectives.c. Timeline. We suggest using a Gantt chart to provide a timeline to achieve key activities and

[sub-] objectives. d. Expected deliverables. Please describe the expected deliverables of the project (including

the submission of a completed Mitacs Final Report and Mitacs survey at the end of the project).

e. Benefit to the PhD intern.f. Interaction. Indicate the percentage (%) of time during the project that the intern will spend

on-site at the partner’s location. The expected minimum interaction is 50%, if different, please include a justification.

% of partner interaction: ____ % + % of academic interaction: ____ % = 100%

g. Justification of interaction (if applicable):

2.6. Relevance to the partner organization and to Canada. Describe the partner’s proposed role in the project, the on-site activities happening at their facilities, and how the partner will benefit from participating:

2.7. Project economic orientation (if applicable): if your partner is an eligible not-for profit (NFP) organization, describe the economic or productivity orientation of the project, including the information submitted through the pre-assessment form.

2.8. Relationship (if any) to past/other Mitacs Accelerate internships, Mitacs Elevate fellowships, or current applications in submission to any Mitacs program.

2.9. Cited Literature:

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 3

3.0. Declarations

3.1. Will the proposed research be taking place outside of the lab or normal business environment? Yes/NoIf yes, please complete the following section to indicate what (if any) impact there may be on the environment.

a) Main characteristics of the location (i.e. physical description & coordinates).

b) Principal activity(ies): for each activity, list the environmental elements affected.

c) Are authorizations, permits, or licenses required to undertake any activity during the internship? Yes/No

If yes, please list and include copies with your application.

3.2. Does the proposed research involve living human subjects (including conducting interviews) or human remains, cadavers, tissues, biological fluids, embryos, or fetuses? Yes/No

If yes, the proposal must be reviewed by the participating University Research Ethics Board, and a report by the board must be forwarded to Mitacs as soon as available.Please note: no funds can be released until Mitacs has received the report.

3.3. Does the proposed research involve animal subjects? Yes/No

If yes, the proposal must be reviewed by the participating University Animal Care Committee, and a report from the committee must be forwarded to Mitacs as soon as available. Please note: no funds can be released until Mitacs has received the report.

3.4. Is a biohazards review required? . Yes/No

If yes, the necessary review/report from your university must be forwarded to Mitacs when availablePlease note: no funds can be released until Mitacs has received the report.

3.5. If this project is related to a past/other Mitacs Accelerate internship, is this internship also related to a Mitacs Research Partner with whom we can also share details of this internship proposal?

If yes, name the Research Partner:

3.6. Have any participants declared a Conflict of Interest (COI) as part of this application? Yes/No

If yes, please attach the signed conflict resolution letter.

3.7. How did the participants first hear about Mitacs?☐ Notification from your university department or

at the university (bulletin board posting, email communication, newsletter, university website)

☐ From the university’s graduate studies offices

☐ From a professor at the university☐ From a representative at the sponsor company ☐ From a Mitacs representative☐ Notification from Mitacs (e-mail newsletter,

social media)☐ Other (please describe):

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 4

4.0. Participants (Duplicate relevant section(s) as needed for multiple interns or supervisors.)

4.1. Academic supervisor: Name:

University:Department:

Address (at university):City, Province:

Postal code:Phone:Email:

Québec Only: Please provide your PIN FRQ (ABCDE1234 format): _______________Click here to obtain a PIN FRQ and complete Appendix B

4.1.1. Is the academic supervisor**:An owner or a co-owner of the partner organization: Yes/No A relative of an owner or co-owner of the partner organization: Yes/NoAn employee of and/or a participant in the day-to-day management of the partner organization: Yes/No

**If yes to any of the above, please click here to complete the Conflict of Interest Declaration and send it to accelerate@mitacs.ca BEFORE submitting your application.**

For any additional academic supervisors (copy and paste Section 4.1. below):

4.2. Partner organization:Legal name:

Operating name(if different from legal name)

Contact name:Position:

Department:Address:

City, Province:Postal code:

Phone:Email:

Website:Partner size

(No. employees): Select No. employees.

Legal status: Select Legal Status

4.2.1. NAICS Code (First three digits): _______________Click here for a list of North American Industry Classification System codes.

For any additional partner organization (copy and paste Section 4.2.) below:

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 5

4.3. PhD Intern:

4.3.1. Intern informationName:

Name of PhD degree program during internship:

Expected year of graduation:University:

Department:Address at University:

City, Province:Postal code:

Phone:University email:Alternate email:

Citizenship: Select citizenship.Gender Select gender.

4.3.2. Has the intern had any previous Mitacs and/or Connect Canada funded internships?*

Select Yes/No Start Date End DateMitacs Yes/No Start Date End DateConnect Canada Yes/No Start Date End Date

*If yes to any of the above, you will be required to complete and sign Appendix C, Intern Declaration and Funding Details, with this application.

4.3.3. Conflict of interest. Is the intern**:An owner or a co-owner of the partner organization: Yes/NoA relative of an owner or co-owner of the partner organization: Yes/NoAn employee of and/or a participant in the day-to-day management of the partner organization: Yes/No

**If yes to any of the above, please click here to complete the Conflict of Interest Declaration and send it to accelerate@mitacs.ca BEFORE submitting your application.

4.3.4. Demographic information. *OPTIONAL*.

Please indicate if you are: Francophone: Yes/No A person with a disability: Yes/NoAboriginal: Yes/No First in your family to attend university: Yes/No

Social Media: Please provide usernames if you wish to connect with Mitacs by social media:☐ LinkedIn:☐ Twitter:☐ Facebook:

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5.0. Funding, Budget and Invoicing

For the Accelerate PhD Fellowship, the $30,000 annual grant must support a maximum of $25,000 annual stipend for the PhD student.

The minimum partner contribution is $12,000 per year. Any funds in excess of $12,000 per year may be forwarded with the total grant but will not be matched. The Mitacs contribution remains $18,000 per year. A maximum of $25,000 stipend is recommended, but may be reduced to a minimum of $20,000 if research support costs are high

5.1. Funding summary For each year, the partner must contribute $12,000 min. and Mitacs will match with a max. of $18,000.

Source Years AmountTotal Mitacs contribution ($18,000 maximum per year) 3 $54,000Total Partner contribution ($12,000 minimum per year) $Total internship award ($30,000 per year) 3 $

5.2. BudgetFor each year, the intern stipend must be a maximum of $25,000 and the research costs must be a minimum of $5,000.

5.2.1. Stipend expenses – details per year

Year PhD intern Name Estimated Start date(Month, Year)

Stipend Amount(max. $25,000 per

year)$$$

Total Stipend (A): $

5.2.2. Research costs, e.g. equipment, travel, conference (add extra table lines as needed).

Research Costs Value1. $2. $3. $

Total research costs (B) – which cannot exceed $5,000 per internship unit: $

Total expenses [(A + B) = total PhD internship award] $

5.3. Additional resources Please indicate if the partner will provide the intern with any of the following additional resources and indicate their estimated value:

Additional resources AmountOffice supplies / stationery $Use of equipment or specialized equipment $Access to relevant company material, personnel $Industrial partner supervision $Other, please specify: _____________ $

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 7

5.4. Invoicing Partner fundsPlease describe any applicable invoicing requirements (vendor setup, PO, etc.):

Invoicing contact name:Email:

☐ Address same as filled in Section 4.2.☐..If invoicing address different than Section 4.2, please fill out the following:

Legal name:Address:

City:Province:

Postal code:Phone:Email:

** Please note: Partner contributions must be received by Mitacs BEFORE any funding is awarded to the university. Costs can only be incurred after research approval of the proposal.**Have these funds been leveraged against other federal or provincial programs? Yes/No

If yes, please provide details:

5.4.1. Were partner funds sent, as an exception, to the university? Yes/No

If yes, please confirm that ORS agrees to send these funds to Mitacs and provide ORS contact name

☐ Confirm Name of ORS contact:

5.4.2. GST or HST, and QST (if applicable) to be included with invoice to university? Yes/No

If no, tax(es) will be invoiced directly to the partner

5.4.3. Payment options Industrial Partner must contribute minimum $36,000 over 3 years per PhD Fellowship Grants will be delivered annually as a research grant to the fellow’s academic supervisor Industrial Partner contributions must be sent to Mitacs annually ($12,000 per annum) If requested, up to 2 invoices for $6,000 per year may be granted per PhD fellowship, please

note that invoices will be sent 60 days before the start date of the first internship and 60 days before the mid-year date

Please select the preferred payment option:

☐ Full payment☐ 2 installments

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 8

6.0. Suggested Reviewers Please provide the names and contact information of at least SIX (6) arms-length reviewers.

An arms-length reviewer must:- Be a recognized expert in the research topics and technical aspects covered by the proposal;- NOT be from the same university as the intern(s) or the academic supervisor(s); and- NOT have had any collaboration with the intern(s) or the academic supervisor(s) or the

partner(s) during the past five (5) years or planned for the near future.Please note that neglecting to suggest reviewers who qualify as arms-length will delay the review of your application.

Reviewer 1:Name:

University:Department:

Email:Reviewer 2:

Name:University:

Department:Email:

Reviewer 3:Name:

University:Department:

Email:Reviewer 4:

Name:University:

Department:Email:

Reviewer 5:Name:

University:Department:

Email:Reviewer 6:

Name:University:

Department:Email:

OPTIONAL: Potential competing interest. Include potential reviewers whom Mitacs should not contact due to a potential competing interest in the proposed research.

Name:University / Research Group:

Name:University / Research Group:

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 9

7.0. Mitacs Accelerate MemorandumThe participants listed below confirm that the information presented accurately reflects their intention to apply to the Mitacs Accelerate program. The participants have also agreed to set in place an internship based upon the attached proposal. It is understood that the partner organization contribution shall be provided to Mitacs Inc. prior to commencement of the internship; in the event that the sponsor organization funds are at the university, the university shall forward these funds to Mitacs. Upon research approval, Mitacs shall forward the funds to the university as a research grant to the supervising professor, and the internship stipend will be paid to the student by the university from the grant. Costs associated with this proposal as outlined in the budget can only be incurred after scientific approval of the proposal.

Mitacs is unable to assume liability for any losses including—but not limited to—accidents, illness, travel, or other losses that may occur during the internship period. All undersigned parties agree that they are responsible for ensuring that they have appropriate insurance and meet any university policies regarding health, safety, and travel preparation requirements. All parties also agree that the PhD intern is expected to complete a three (3) year fellowship and provide Mitacs with a final report and that all participants will complete an exit survey within one month of project completion. A replacement of the fellowship intern or transfer to another intern is not accepted.

All parties involved with Mitacs Accelerate are bound by the standard intellectual property (IP) terms of the university where the intern is enrolled; except where intellectual property is covered by separate agreements to which the university and the sponsor organization are parties and that are active during the dates of the internship. By signing this memorandum, you are acknowledging that you agree to the terms of the university where the intern is enrolled. University-specific IP policies regarding Accelerate internships can be found at Accelerate Policies and Procedures.

The participants listed below agree that Mitacs can disclose the provided personal information included in this proposal (e-mail, LinkedIn, Twitter, Facebook, etc.) to the program’s funding partners and that Mitacs can use them for the purpose of communication and to evaluate the program and its outcomes during and after participants’ program tenure. The participants also agree that Mitacs will post the title of the project, the public project overview, the name of the partner(s) organization(s), the name of the intern(s), the name of supervisor(s) and the involved university on www.mitacs.ca/en/projects and may be used by Mitacs to publicize Mitacs Accelerate. Mitacs Privacy Policy can be found at www.mitacs.ca/en/privacy-policy .

Internship participants (intern, supervising professor, and partner) further agree to the following addendum(s):

Mitacs does not require, inspect, or enforce any additional terms as outlined by participants in the above addendum.

Title of the Project:

Public Project Overview: Using simplified language understandable to a layperson; provide a general, one-paragraph description of the proposed research project to be undertaken by the intern(s) as well as the expected benefit to the partner organization. (100 - 150 words)

Accelerate PhD Fellowship – Proposal Application – March 2015 Page 10

Participant Signatures:

PhD Intern:Name:

Department:University:

Signature: Date:

Academic Supervisor:Name:

Department:University:

Signature: Date:

Partner Organization:Name:

Department:Title/Position:

Partner Organization:

Signature: Date:

University Office of Research Services Representative:Name:

Title/Position:

University:

Signature: Date:

For any additional participants include corresponding details and signature line below:

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Appendix A (Please delete if not applicable)

Ontario Interns ONLY

Notice of Collection of Personal Information and Consent

The Ministry of Training, Colleges and Universities (the Ministry) provides a financial contribution to Mitacs Inc. to support the Mitacs Accelerate program (the Program) under which you will receive a graduate internship in Ontario. Under the financial contribution agreement with the Ministry, Mitacs is required to report on the Program and its expenditure of the funds provided by the Ministry, including reports on your participation in the Program. Mitacs is also required to give the Ministry and its contractors and auditors access to all its records, if necessary to review, inspect, investigate, monitor, and audit its performance of the obligations under its agreement with the Ministry.

The Ministry may also use your personal information to evaluate the results of the Program. In addition, the Ministry, and/or its contractors may want to contact you to seek your opinion about the Program. The Ministry would need to obtain your contact information from Mitacs for these purposes.

By signing below, you give consent to the Ministry to collect personal information about you from Mitacs and to use it for the purposes set out above.

The Ministry collects your personal information in compliance with s. 38(2) of the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F. 31, as amended.

If you have questions about the collection and use of your personal information, you may contact Director, Postsecondary Finance and Information Management Branch, Ministry of Training, Colleges and Universities, 7th Floor, Mowat Block, 900 Bay Street, Toronto, Ontario, M7A 1L2 or call (416) 325-1952.

Signature___________________________________ Date _____ / ______ / ______Day Month Year

Print Name__________________________________(name of student/ PDF)  

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Appendix B (Please delete if not applicable)

Quebec Supervisors ONLY

(Please complete and sign ONE Appendix B per each participating supervisor)

COMMITMENT

I agree that the conditions governing the program described in the rules of the Quebec Accelerate program (http://www.mitacs.ca/en/programs/accelerate/program-details) apply to any grant that will be given to me as a result of this request.

I certify that all information provided is accurate and complete, and I agree to report without delay any change to any information submitted.

☐ I agree ☐ I refuse

CONSENT

All personal or scientific information collected by the Fonds de recherche du Québec - Nature et technologies are subject to the Act respecting access to documents held by public bodies and the Protection of Personal Information (Access Act). The Fund must ensure the confidentiality of this information and communicate with the consent of the person concerned or of the person signing the application or in accordance with the Act.

The data collected by the Fund will only be used to:

• determine eligibility of applications;• select committee members;• assess applications;• manage the programs;• conduct inventories, assessments, surveys or analyses within the framework of its mandate and in accordance with the Access Act in this regard.

These activities may require the exchange of information with the attachment of the applicant institutions. Hereby, the applicant authorizes the Research Fund for Québec - Nature et technologies to communicate with the institutions concerned connecting to exchange any information relating to the implementation of the activities listed above.

☐ I agree ☐ I refuse

Quebec Supervisor Name __________________________________ Date _____ / ______ / ______Day Month Year

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Appendix C (Please delete if not applicable)

Intern Declaration and Funding Details:

You must complete the following standard declaration to state how many internships (0, 1, 2, etc.) you have completed to date under the Mitacs Accelerate and Connect Canada programs. Do not include the internships in this proposal in the number of internships declared; only successfully completed internships are to be declared.

 Number of Internship Grants Completed:

I certify that I, __________________________ have completed (name of student/ PDF)  

___ funded internships through the Mitacs Accelerate Program, and

___ funded internships through the AUTO21 Connect Canada program.  

Please note that interns are eligible to receive a limited number of internships per lifetime. Misrepresentation of this information will result in withdrawal of funding and will be reported to the applicant’s institution.

Year of first internship (if applicable)           _______

Year of second internship (if applicable)          _______

Signature of Intern/ PDF:      ____________________________________

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