Aspen Spinal Bracing Rehabilitation Research Grant Application

Aspen Spinal Bracing Rehabilitation Research Grant Application

Must be received by May 1

Contact Information

To complete form, click in table cell and type information. Cells will expand to fit longer entries.

Name of Applicant (last, first, middle initial):
Address:
Office Phone: / Year completed residency:
Home Phone: / Status: / Board Eligible
Fax Number: / Board Certified, Year
E-Mail:
Date of Birth:

Co-Investigators (If the applicant is not a member of the AAPM&R or AAP, at least one of the co-investigators must be.):

Name:
City/State:
Name:
City/State:
Name:
City/State:
Name:
City/State:

Institution at which the research will be performed:

Name:
Address:

Applicant Signature (can be inserted electronically) Date

Foundation for PM&R Aspen Spinal Bracing Rehabilitation Research Grant Application

Aspen Spinal Bracing Rehabilitation Research Grant -

Description of Research Project

Title of project:

Goals/purpose of project (narrative format - 2 page max):

Objectives of project (outline format - 1 page max):

Project plan - procedures and methods (outline format – 2 page max):

Relationship of anticipated results to general problems in spinal rehabilitation (1 page max):

APPENDIX I

Proposed budged (total budget; may include administration costs but not PI salary, travel or enduring equipment). Indirect costs should not exceed 10% maximum and must be included in the total budget. Include a brief summary to justify costs.

Any application for other concurrent support? / No / Yes (if yes, complete below)
Source / Name of Program / Type of Support / Amount of Support

APPENDIX II

Facilities available (to include space, equipment, etc.) at your disposal to carry out the proposed research:

APPENDIX III

Summary of publications and presentations in support of this project (list in chronological order; please do not bold or otherwise highlight your name if it appears in this list):

APPENDIX IV

Summary of previous successful research work and results done by you (list in chronological order; please do not bold or otherwise highlight your name if it appears in this list):

APPENDIX V

Your research career goals:

APPENDIX VI - Curriculum Vitae

Please include a copy of your Curriculum Vitae with application.

Foundation for PM&R Aspen Spinal Bracing Rehabilitation Research Grant Application

Aspen Spinal Bracing Rehabilitation Research Grant -

Human Subjects Approval Form

Are human subjects being used in research?

No / Yes / If yes, has proposal been approved by institution’s human subjects committee?*
Yes / If yes, have the Human Subjects Approval Form (below) completed by an official authorized to sign on behalf of institution’s human subjects committee.
No / If no, please give reason below:

*If an IRB application has been submitted but approval has not been received, please indicate here and forward the approval notice to the Foundation office by May 1. If IRB application approval has not been received by July 1 you may be asked to resubmit your application in the following grants cycle.

 IRB has been submitted for approval and is in process.

This application has been reviewed and approved by the institution’s committee on use of human subjects for the proposed research.

Name:
Title:
Date:
Signature:

Please return completed application via e-mail to: Phyllis J. Anderson, M.A. at , Applications submitted by mail or fax will not be accepted. If you have questions, e-mail or call (847) 737-6062.

Foundation for PM&R Aspen Spinal Bracing Rehabilitation Research Grant Application