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Investigator-Initiated Study (IIS) Grant Request Form

Supporting independent medical research that advances human health

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We proudly support researchers, clinicians and institutions that conduct research to advance medical treatment and the standard of care for patients. In an Investigator-Initiated Study, the investigator and/or institution assumes responsibility for all aspects of a study including patient safety and integrity of the data. IIS Grants are awarded based on scientific merit, including unmet medical need, as well as study feasibility and availability of funds.

The following documentation is required during an IIS study proposal request:

Study protocol

Study budget

In the case of human subjects, IRB approval/exemption letter if obtained already

Prior to initiation of the IIS, the following will be required:

Fully executed investigator-initiated research agreement between the requesting organization and B. Braun

IRB approval/exemption letter if human subjects are involved

If your IIS falls within our areas of focus as described above, we invite you to request a Grant from B. Braun. For any questions, or if you encounter any problems, please send us an email at GrantRequests@bbraunusa.com.

Investigator-Initiated Study (IIS) Grant Request Form

Requesting organization name *

Requesting organization address line 1 *

Requesting organization address line 2

Requesting organization city *

Requesting organization state *

Requesting organization zip code *

Requesting organization country *

Requesting organization tax ID number *

Requesting organization type *

Principal investigator name *

Principal investigator job title *

Principal investigator email *

Principal investigator phone *

Study protocol title (please attach protocol) *

Study description *

Requested dollar amount (0 (zero) if product donation only, do not use any symbols in this field, only numbers. I.e. do not use $ or ,) *

Are you requesting a product donation to support the study? If so, please identify the product name (or SKU), description, and quantity of the product needed for the study. *

Describe how the grant and/or product donation will be used for the study. *

Product shipping information (may not be to a personal address) if products are requested and if different from organization or principal investigator information provided above:

Organization name *

Organization address *

Contact name *

Contact email *

Contact phone *

The following supporting documentation must be attached and submitted with the IIS Grant Request Form:

1. Study protocol *

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2. Study budget (if requesting money)

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3. IRS form W9 *

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4. If requesting products a complete list of the products requested using the product name (or SKU) and quantity of each. This information can be found on B. Braun’s website.

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By submitting this request, I acknowledge the B. Braun will require a signed agreement in the event my request is approved and before providing the approved support.

Supporting independent medical research that advances human health

Investigator-Initiated Study (IIS) Grant Request Form

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