Submit a New Disparities in Healthcare Grant Application RESEARCH: Grant Application Principal Investigator(Required) First Middle Last Suffix Principal investigator must be a SAGES MemberIs the Principal Investigator a Young Investigator?(Required) Yes No SAGES considers a Young Investigator as someone who has not practiced surgery independently for more than 5 years.CorrespondencePlease use the following information for all correspondence regarding this grant applicationInstitution Department Professional Title Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Administrative Contact First Last Phone(Required)Email(Required) Grant InformationType of Grant(Required) General Grant Robotic Surgery Research Grant DEI (Disparities in Healthcare) AI Grant Project Title(Required)Total Amount Requested(Required)Start Date for Project(Required) MM slash DD slash YYYY End Date for Project(Required) MM slash DD slash YYYY Co-InvestigatorsNameInstitutionProfessional Title Add RemovePlease use the + icon to add new rows for new co-investigatorsHiddenBudget Justification(Required)Please provide a short paragraph justifying the requested budgetGrant Application Terms and Conditions(Required) I agree to the terms below. If awarded, requested follow up information must be provided to the SAGES Research and Career Development Committee. Investigators are required to submit semi-annual updates to the SAGES Research Committee during the course of the research, starting six (6) months after the grant has been awarded. At the conclusion of the project, the investigator is required to submit a final update report to the Research Committee. If the updates are not sent, SAGES may need to recover the monies awarded. An abstract must be submitted for the SAGES Scientific Session which immediately follows the successful completion of the work. A manuscript on the study and your findings must be sent to Surgical Endoscopy. A copy of the final manuscript must be sent to the SAGES office in order for the grant to be considered complete. SAGES must be acknowledged as a funding source. Appendices will not necessarily be reviewed. Add appendices at your own risk. Submissions exceeding the page limit will not be reviewed. If these terms and conditions are not met, subsequent applications from the PI and co-PI will be viewed unfavorably for future funding through the SAGES research grant program for 2 years.Disclosures/Conflict of InterestPlease disclose any employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications, research/travel grants, etc. for the Principal Investigator and each of the co-principal investigators. Must also include prior funding received from SAGES.Has anyone listed in your grant received prior funding from SAGES?(Required) Yes No PI Disclosure(Required)Anything to Disclose (Y/N)If Y, list companies, roles, what was received, year prior SAGES funding received Add RemovePlease use the + icon to add new rows for new company disclosures. If you have nothing to disclose, enter N on the first line. Must also include any prior funding from SAGES and the year funding was received.Co-PI DisclosuresCo-PI NameAnything to Disclose (Y/N)If Y, list companies, roles, what was received, year prior SAGES funding received Add RemovePlease use the + icon to add new rows for new Co-PIs and/or new company disclosures. If all Co-PI's have nothing to disclose, create new rows for each Co-PI and enter N under Anything to Disclose. Must also include any prior funding from SAGES and the year funding was received.Upload the Complete Grant ApplicationGrant File(Required)Accepted file types: pdf, Max. file size: 600 MB.Please upload your grant application as a single PDF file labeled as: General Grant: General_Last NameFirst Initial_date.pdf (e.g. General_DoeJ_08Nov20.pdf) Robotic Grant: Robotic_Last NameFirst Initial_date.pdf (e.g. Robotic_DoeJ_08Nov20.pdf) Before uploading final grant application, please review the following: General Grant Instructions Robotic Grant Instructions Available Templates: General Grant Template Robotic Grant Template Appendices will not necessarily be reviewed. Add appendices at your own risk. Submissions exceeding the page limit will not be reviewed.HiddenOther Supporting Files (Budget Sheet)Accepted file types: pdf, zip, doc, docx, Max. file size: 600 MB.HiddenMemberID PhoneThis field is for validation purposes and should be left unchanged.