Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

Password must contain the following:

12 Characters
1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

Page 1

Call for Applications:

MCW-Led Momentum Grants

Eligible MCW faculty are invited to submit the following letter of intent (LOI) through this online form to apply for AHW’s Call for Applications: MCW-Led Momentum Grants funding opportunity.

The application must be completed and submitted using this online form and no paper or emailed applications will be considered. This application form only supports Plain Text and no text effects such as bold, italics, underlining, bulleting, numbering, etc. will be captured in the form fields in the final submission. No attachments beyond those requested in the call for applications and online form will be accepted.

Please refer to the MCW-Led Momentum Grants funding opportunity page on the AHW website for additional instructions and requirements.

The deadline for submission is November 4, 2024 by 5:00 p.m. CT. Late applications will not be accepted.

Please note that all fields marked with * are required.

AHW does not discriminate against individuals on the basis of age, race, creed, religion, color, disability, marital status, sex, national origin, ancestry, sexual orientation, gender identity, arrest record, conviction record, membership in the national guard, state defense force or any other reserve component of the military forces of the United States or the State of Wisconsin or use or nonuse of lawful products off MCW’s premises during nonworking hours.

Project Information

Project Title

Award Budget

Total Amount Requested:

(in whole dollars and

not to exceed $250,000 maximum)

Additional Funds:

(if applicable)

Source of Additional Funds:

(if applicable)

Start Date:

Duration of funding:

(in months and

not to exceed 24 months maximum)

Goal Statement - Please provide a brief statement describing the goal of the proposed project, including the intended impact on health and/or health equity in Wisconsin. (maximum 400 characters, including spaces)

Project Summary – Please provide a brief project summary including Wisconsin-based health need and why it is a priority, the proposed approach to address the identified health need, and the intended impact that the proposed project will contribute towards achieving. (maximum 2,000 characters, including spaces)

Project Team Information

MCW School of Medicine Principal Investigator

MCW School of Medicine Principal Investigator – Applicant teams must designate one (1) eligible MCW School of Medicine Principal Investigator (PI). PIs must be full-time or full professional effort MCW faculty with the rank of Assistant Professor, Associate Professor, or Professor with a primary appointment in the School of Medicine. See the call for applications for MCW PI eligibility requirements. Collaboration among partners is encouraged, but compliance with fiduciary and reporting requirements are the responsibility of the PI.

MCW PI Contact Information


MCW PI Name:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone:

Cell Phone:

Email:

MCW Standing:

Full-time facultyFull-professional effort status

MCW Department:

Co-Investigator(s)

Co-Investigator(s) – Project team must designate at least one (1) eligible MCW Co-Investigator (Co-I) and are encouraged to designate additional Co-Is, as appropriate to ensure the necessary skill sets and expertise are engaged in the project team. The MCW Co-I must be full-time or full-professional effort MCW faculty. See full RFA for eligibility requirements. Please note that the online form is limited to five Co-Is total.

1. Co-I Contact Information


MCW Co-I Name, MD/PhD:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone Number:

Email:

MCW Standing:

Full-time facultyFull-professional effort status

Department:

Add additional Co-Investigator(s)?

2. Co-I Contact Information


Co-I Name, MD/PhD:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone Number:

Email:

Institution:

Department:

Add additional Co-Investigator(s)?

3. Co-I Contact Information


Co-I Name, MD/PhD:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone Number:

Email:

Institution:

Department:

Add additional Co-Investigator(s)?

4. Co-I Contact Information


Co-I Name, MD/PhD:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone Number:

Email:

Institution:

Department:

Add additional Co-Investigator(s)?

5. Co-I Contact Information


Co-I Name, MD/PhD:	First	Middle	Last	Suffix/Credentials

Preferred Name:

For example, enter 'John' if that is your preference rather than Johnathan.

Pronouns:

Title:

Work Phone Number:

Email:

Institution:

Department:

Collaborator(s)

Collaborators(s): Please list additional key members of the project team to demonstrate that the project team brings together individuals with the necessary skill sets, experience, influence, and expertise to carry out the project. Any individual and/or organization listed as a collaborator should be committed to the proposed project and ready to engage in the project based on their specified role, if funded. Collaborators are not subject to MCW faculty eligibility requirements. Please note that the online form is limited to ten collaborators.

Name:	Institution/Organization:	Department:

Narrative

Please see the Call for Applications: MCW-Led Momentum Grants for the narrative prompts and instructions.

Attach completed Narrative (PDF) here:

Review Information

The questions below will be used to guide the merit review of your proposal at the LOI and, if applicable, full proposal stages.

Merit reviews at both the LOI and full proposal stages will be completed by a review body. Please identify which panel your proposal best aligns with. Preference for a particular panel does not guarantee review by that panel.

Health workforce review panelBasic science review panelClinical science review panel Population science review panel

At the full proposal stage, each application will also receive review by an external expert as recommended by the applicant. In anticipation of the full proposal review, please provide at least two and up to four recommendations of external (non-MCW) experts to serve as external reviewers for your full proposal application. Should you be invited to the full proposal stage, one of your recommendations may be selected to serve as an external reviewer.

Please follow the criteria below when making reviewer recommendations:

External reviewers should be more senior in appointment
External reviewers may not have been employed at MCW within the last three years
External reviewers may not have been a collaborator or had any other professional relationships with the applicant PI or Co-I(s) within the last three years

1. External (non-MCW) Reviewer


Name:	First	Middle	Last	Suffix/Credentials

Preferred Name:

(if unknown, list first name)

For example, enter 'John' if that is your preference rather than Johnathan.

Institution:

Title:

Work Phone Number:

Email:

Area of Expertise:

2. External (non-MCW) Reviewer


Name:	First	Middle	Last	Suffix/Credentials

Preferred Name:

(if unknown, list first name)

For example, enter 'John' if that is your preference rather than Johnathan.

Institution:

Title:

Work Phone Number:

Email:

Area of Expertise:

Are there additional non-MCW reviewer recommendations?

3. External (non-MCW) Reviewer


Name:	First	Middle	Last	Suffix/Credentials

Preferred Name:

(if unknown, list first name)

For example, enter 'John' if that is your preference rather than Johnathan.

Institution:

Title:

Work Phone Number:

Email:

Area of Expertise:

Are there additional non-MCW reviewer recommendations?

4. External (non-MCW) Reviewer


Name:	First	Middle	Last	Suffix/Credentials

Preferred Name:

(if unknown, list first name)

For example, enter 'John' if that is your preference rather than Johnathan.

Institution:

Title:

Work Phone Number:

Email:

Area of Expertise:

Hidden

PI Account ID

Save my progress and resume later | Resume a previously saved form

Contact Information

Gender Identity – How do you publicly self-identify? FemaleMaleGender nonbinary/Genderqueer/Gender non-conformingOtherDecline to state	Gender Identity – How do you publicly self-identify? Transgender Not transgender (cisgender)Decline to state
Please describe:

Race – How do you publicly self-identify? Please select all that apply. Asian American/Pacific Islander/AsianBlack/African American/AfricanLatino/Latina/LatinxNative American/American Indian/IndigenousWhite/Caucasian/EuropeanMulti-racial/Multi-ethnic (two or more races or ethnicities)Different identityDecline to state	Ethnicity – How do you publicly self-identify? Hispanic or Latino/Latina/LatinxNot Hispanic or Latino/Latina/LatinxDecline to state
Please specify:

Sexual Orientation – How do you publicly self-identify? Heterosexual or straightGay, lesbian, bisexual (or other sexual orientations within the LGBTQIA+ community) Different identityDecline to state	Disability Status – How to you publicly self-identify? I identify as a person with disabilityI do not identify as a person with a disabilityDecline to state
Please specify:

Page 1

Page 2