GRANT PROPOSAL - 2018 CLINICAL PROJECT GRANT
A. Application [CIA Surname: Click here to enter text.]
RAH SPF Private Practice Contributor Name: Click here to enter text.1. Title of Proposal
Click here to enter text.2. Applicant(s)
a)Principal Investigator
Surname: Click here to enter text. First: Click here to enter text.
Title: Click here to enter text.
Position: Click here to enter text.
Current Employer: Click here to enter text.
Department: Click here to enter text.
Work Address: Click here to enter text.
Telephone: Click here to enter text.
Email: Click here to enter text.
Associate Investigator(s) if applicable Copy and paste if more required
Surname: Click here to enter text. First: Click here to enter text.
Position: Click here to enter text.
Current Employer: Click here to enter text.
Department: Click here to enter text.
Work Address: Click here to enter text.
Telephone: Click here to enter text.
Email: Click here to enter text.
b)
Project Details: Click here to enter text.
Department Project being carried out: Click here to enter text.
What part of the study is being conducted at the RAH (give details): Click here to enter text.
Where else will this study be conducted? (Please tick those applicable)
☐SAHMRI ☐UNISA ☐University of Adelaide ☐SA Pathology
☐Other: Click here to enter text.
Hours per week on project (for each investigator): Click here to enter text.
3. Application for other Research Support Currently Pending
Click here to enter text.4. Current Research Support
Click here to enter text.5. Relationship of this Application to Other Funding
Click here to enter text.6. Ethics Approval
NB: All projects require current ethics specific to the project.
Ethics application submitted ☐ Ethics Reference Number: Click here to enter text.
7. Statement on Ethical Considerations (1/2 page maximum)Data and/or samples security and confidentiality:
☐ Non-identifiable ☐ Re-identifiable ☐ IdentifiableClick here to enter text.
8. Drugs (if applicable)
Click here to enter text.9. Certification (Attached as separate document)
10. Scientific Reviewers
1. Full Name: Click here to enter text.Position: Click here to enter text.
Phone: Click here to enter text.
Email: Click here to enter text.
2. Full Name: Click here to enter text.
Position: Click here to enter text.
Phone: Click here to enter text.
Email: Click here to enter text.
3. Full Name: Click here to enter text.
Position: Click here to enter text.
Phone: Click here to enter text.
Email: Click here to enter text.
B. research PROPOSAL
1. Purpose of Study (1/2 page maximum)Click here to enter text.
2. Budget (1/2 page maximum)
CALHN Cost Centre funds to go into:
Existing ☐ # Click here to enter text. New ☐
Budget Details:
Budget Item / Details
Provide details of expenditure / Funds/costs to:
External Party eg. University, SAHMRI etc. / Amount
Salaries
Name (if applicable)
Rate, Level etc.
Consumables
Equipment
Other
TOTAL
3. Justification of Budget (1/2 page maximum)
Click here to enter text.
4. Aims (1/2 page maximum)
Click here to enter text.
5. Background and Research Plan (3 pages maximum)
Click here to enter text.
6. References (Asterisk up to 6 key references - 1 page maximum)
Click here to enter text.
7. Analysis and Reporting of Results (1 page maximum)
Click here to enter text.
8. Date of Proposed Commencement
Click here to enter a date.
C. PREVIOUS RESEARCH ACTIVITY AND ACHIEVEMENTS
1. Curriculum Vitae of Principal Investigator (not to exceed 10 pages)Click here to enter text.
2. Previous Research Support (not to exceed one page)
Click here to enter text.
3. Publication History
(maximum of 8 most relevant recent publications - no abstracts)
Click here to enter text.
Revised 01/08/17 4