2018 WCHRI Clinical/Community Research and Integration Support Program (CRISP)

Application FormApplication Deadline September 17, 2018 at 4:00pm

Research Grants Administration, 5-083 ECHA, University of Alberta, Edmonton, T6G 1C9

Instructions for completion of the application form Read the complete application and guidelines before you start. Complete the application form. Do not exceed the space provided. Additional pages may be

provided only where indicated and must be provided in Calibri 10 pt font size. All margins are restricted to no less than 2 cm. Additional pages or information may be appended only where indicated and must include the applicant’s name in the header and the page number in the footer (page 7a, 7b, 7c, etc…).

Do not submit material that is photo-reduced or stapled. Double-sided information is not accepted.

Do not forward or send supporting documentation directly to WCHRI. All supporting documentation must accompany the application.

Principal investigatorWCHRI defines a principal investigator as an individual who will be responsible for the direction of the proposed activities and assume the administrative and financial responsibility for the grant or award; andreceive all related correspondence.

Name of Principal Investigator: Last Name, First Name, Middle Initial(s)

Confirmation of WCHRI membership YES NO If not a member, complete the membership application prior to submission of this application.

SignaturesThe undersigned agree to abide by UAPPOL and WCHRI Innovation program guidelines governing any award made pursuant to the sponsorship of this application.Required Signatures Printed Name Date (day/month/year)Principal Investigator       dd/mm/yy

Department Chair       dd/mm/yy

Faculty Dean       dd/mm/yy

Research Services Office       dd/mm/yy

Principal investigator: Last Name, First Name

Mentorship and research team summary List the individuals who will form the research team. For individuals not employed or affiliated with the University of Alberta, indicate their organizational affiliation (e.g. Alberta Health Services, Covenant Health, Primary Care Network, clinical or community-based organization, other University). All mentors and research team members must have a regular/on-going and full-time appointment with the affiliated university or organization.

Research mentorshipA research mentor is an individual who will share knowledge and provide advice at all phases of the research (proposal development, ethics submission, data collection, data analysis, dissemination/implementation of findings). WCHRI strongly encourages all applicants to include a research mentor on the team, however a research mentor is required if the principal investigator has less than 40% protected research time. The research mentor is not expected to engage in any aspect of completing the work, but rather remains a resource to the team and more particularly the principal investigator.

All research mentors should be established in their field of research. You may not include more than 2 mentors on the team.

Primary research mentor Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Research mentor – if applicableName Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Letter of mentor supportA letter of mentor support is required for all applicants whose applications include a mentor on the research team. Refer to CRISP Information for Mentors for further information. The letter must be signed by the mentor, be currently dated and on appropriate letterhead. Append your letter of mentor support after this section.

The primary task for the research mentor is to ensure that the project remains on time and on task as outlined in the application (specifically in the research proposal, work plan and KT plan sections). In addition, mentors are asked to clearly detail:

The mentor’s engagement in the development of this research proposal, and The mentor’s commitments (feedback, meetings, contributions to overall research direction, etc.)

to foster/ support the principal investigator’s engagement in research.

Principal investigator: Last Name, First NameResearch team members: Co-investigatorsA co-investigator is an individual who contributes to the overall proposed research activities. A co-investigator’s engagement in the project should be evident over the course of the proposed work and may include either i) an engagement to complete the project (as a whole) or ii) intellectual contributions to the project design. Often, co-investigators will present with both contributions to the design and a commitment to completing the work. Research Associates, nurses and other clinical/community personnel may be included as co-investigators. Additional documentation and/or letters from co-investigators are not required and will not be provided to committee for review.

By signing below, it is understood that each co-Investigator agrees to abide by UAPPOL and the WCHRI CRISP Grant Guidelines. The signature of each co-Investigator is required (electronic signatures are acceptable). No more than 4 co-investigators may be listed. Submit the completed WCHRI CRISP Grant Biosketch for each co-investigator listed below.

Co-investigator 1Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Signature:

Co-investigator 2Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Signature:

Co-investigator 3Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Signature:

Co-investigator 4Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Signature:

Principal investigator: Last Name, First NameResearch team members: CollaboratorsA collaborator is an individual whose role in the proposed activities is to provide a specific service or resource (e.g., access to equipment, space, or a patient/community population; training in a specialized technique, such as statistics or qualitative methods).

Please list below the collaborators that will work on the proposed research project. No more than 3 collaborators may be listed.

Collaborator 1Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Collaborator 2Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Name Last Name, First Name, Middle Initial(s)Department/Faculty       University or

Organization

     

Collaborator 3

Letters of collaborationLetters of collaboration from each collaborator must be submitted with this application and should clearly detail the individual’s involvement and role in the proposed research project. Each letter of collaboration must be signed by the collaborator making the commitment, be currently dated and on appropriate letterhead. Applicants are encouraged to refer to the CIHR resource Writing Letters of Support for further information.

Letters of supportLetters of support are not required and will not be provided to committee for review/consideration.

Stakeholder/partner informationAll applicants are required to engage a stakeholder and/or community partner that will work with the research team for the duration of the project (i.e. beginning to end);

Identification of stakeholder/partner Primary contact name & title           Complete mailing address Contact information      Telephone: (780)      

Fax: (780)      

Email:      

Principal investigator: Last Name, First Name

Role of the stakeholder (patients/community groups/organizations) in the studyDescribe the stakeholder’s role in the project, clearly detailing their level of engagement in the project development, commitment to executing the project and engagement in the knowledge translation activities.

     

Stakeholder (patient/community) engagement in health research Detail how engaged research is a good fit for this project.

     

Principal investigator: Last Name, First Name

Relevance criteriaPlease indicate below whether this proposal aims to improve or impact outcomes for children and/or women. For research that proposes outcomes for both women and children, select both checkboxes. Please refer to our website for information on WCHRI relevance criteria. Children’s health Women’s health

Location of proposed researchPlease provide a brief description of the location where the research will be taking place – if patient oriented or community-based research, please indicate the clinical or community setting (e.g. 2E Stollery Ambulatory Clinic, Maternal-Fetal-Medicine Clinic, North East Community Health Centre, etc.)

Department/Faculty, Hospital, Clinic, Community, or other

     

Room Number and Building (if applicable)

     

Ethics informationIndicate whether the proposed research requires the following ethical approvals. The principal investigator is responsible for ensuring that applications have received appropriate ethics, animal certification or biohazards approval. Awarded CRISP Grant projects must evidence ethics approval(s) at RSO for release of funding; all required ethics approvals must list WCHRI as the funder.

Animal Care Approved In Process Not required Human Subjects (HREB) Approved In Process Not required AHS Administrative Approval Approved In Process Not required Biological & Genetic Therapeutics Directorate (Health Canada) Approval

Approved In Process Not required

Biohazard Certification - Level       Approved In Process Not required

Principal investigator: Last Name, First Name

Lay informationThis information may be used to inform our stakeholders or others and/or to promote the work in the media. It is very important for you to be able to share your research with the general public.

Lay title and summary Please provide a lay title and summary of the research proposed in this application. This information may be used and/or released publicly for communication initiatives. Ensure that the language is suitable for a broad/ lay audience (grade 8 level). Do not use scientific or technical language. Successful applications that present with lay information that is not suitable will be returned by WCHRI to the principal investigator for amendment.

Lay title     

Lay summary     

Principal investigator: Last Name, First Name

How does this proposal relate to women and/or children’s health In the space provided below, detail the relationship of the proposed research to women’s and/or children’s health and relevance (direct or indirect) to the Stollery Children’s Hospital and/or Lois Hole Hospital for Women.

     

Work plan List the main tasks involved in the completion of the research project. Estimate the work end date for each listed item. The period of support for this grant is three (3) years. Additional pages may be used.

Milestones work start date

work end date

Participant recruitment (if applicable) dd/mm/yy dd/mm/yyData collection dd/mm/yy dd/mm/yyData analysis dd/mm/yy dd/mm/yyReview and interpretation of findings dd/mm/yy dd/mm/yyManuscript preparation (or other KT output) dd/mm/yy dd/mm/yy      dd/mm/yy dd/mm/yy      dd/mm/yy dd/mm/yy      dd/mm/yy dd/mm/yy      dd/mm/yy dd/mm/yy      dd/mm/yy dd/mm/yy

Principal investigator: Last Name, First Initial

Title of proposed researchPlease provide the scientific title of the work proposed in this application below.

     

Research project Please provide an outline of your research proposal, including a concise summary of the current state of knowledge relating to the work proposed. The objectives and research plan must be clearly detailed and rationale for the choice of particular methods and approaches addressed. The roles and responsibilities of each co-investigator must be clearly detailed in the research proposal.

Append to this section of the application form the following: a three (3) page maximum research proposal. the reference or citation list for your research proposal (no page limit) and If applicable, a maximum of two (2) pages of figures and/or surveys that directly support the

research proposal may be included.

Principal investigator: Last Name, First Initial

Knowledge translation plan In the space below, provide a knowledge translation plan that details processes or mechanisms involved in communicating the outcome/findings/impacts of the proposed research. Knowledge translation may include outputs such as: publication, presentation, handouts/brochures (in the community or hospital), change in practice or care pathway, policy change, social media or web based tools, other types of patient or public facing publication. Refer to our website for more information on knowledge translation resources.

     

WCHRI

Principal investigator: Last Name, First NameBudget request – summaryThe budget may only include expenditures for the proposed research project. The budget summary represents the total budget request and may not exceed $20,000. Refer to CRISP Program Guidelines for eligible and ineligible expenses. If publication of the research is an expected KT outcome, then publication costs must be included in this budget request.

Personnel Description/ Details Amount

Requested

                                 

Materials, Supplies and ServicesDescription/ Details Amount

RequestedExpendables                                       

Research EquipmentDescription/ Details Restricted to not more than 20% of the total project budget.

Amount Requested

           

Knowledge TranslationDescription/ Details Amount

Requested

Travel/conference - Limited to $2,000.00 (total) for conference attendance and includes transportation, registration fees, per diem/ meals, and accommodation, etc.).

     

Publication costs including open access                 

OtherDescription/ Details Amount

Requested                      

Total budget request (may not exceed $20,000.00)Budget TOTAL      

Principal investigator: Last Name, First Name

WCHRI

Budget request - justification Please detail the expenses listed with a clear justification. Quotes for services may be appended to this justification as appropriate.

     

WCHRI

Principal investigator: Last Name, First Initial

Principal investigator bio-sketchProvide a WCHRI CRISP Grant Biosketch for the principal investigator.

Principal investigator summary of other funding For each grant/award listed as currently held or pending (including potential submissions), on the principal investigator’s grant funding list, provide the information listed below. Please ensure that the status of each grant/award is clearly provided with the corresponding period of support.

A copy of the summary page of the application; A statement on the conceptual and budgetary overlap with this application.

Eligibility to hold WCHRI CRISP Grant funds may be impacted by compliance in funding overlap declaration.

Co-investigator bio-sketch(es)Provide a WCHRI CRISP Grant Biosketch for each co-investigator.

WCHRI