Research Grant Application Form

Sigma Theta Tau/Nu Iota Chapter

Research Grant Application Form

Date:

1.Title of Project:

Principal Investigator:

2.Name:

3.Institutional information (Employer or school where currently enrolled):

4.Preferred Mailing Address:

5.Business Phone:

Fax:

Home Phone:

E-mail:

6.Registered Nurse in State(s), Province/Country of:

7.Sigma Theta Tau Member: Yes No If yes, please list your chapter(s):

8.Have you ever received a Sigma Theta Tau International Small Grants Research Award:Yes___ No____ If yes, please list the date(s):

9.Are you now receiving, or have you received, any support for this project from any source (Other support is defined as all funds or resources, whether Federal, non-Federal, or institutional, available to the Principal Investigator in direct support of the research endeavors through research or training grants, cooperative agreements, contracts, fellowships, gifts, prizes and other means. Please indicate sources and amount:

10.Amount requested from Sigma Theta Tau International (U.S. Dollars): $

11.Total Budget of the Project (A budget must be submitted with the application): (U.S. Dollars) $

12.Human subjects involved?:YesNo

Animal subjects involved?:YesNo

Institutional Review Board Action (include a copy of the approval):

Approval Date:

13.Starting Date of Project:

Proposed Completion Date:

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If my proposal is approved for funding by the Board of Directors, I agree to the following:

1.Assume any and all tax liability for research funds that are issued in my name

2.Assume responsibility for the scientific conduct of this research

3.Return the remaining funds to Nu Iota, Sigma Theta Tau International, if my research is not finished by the projected completion date, unless, an extension has been granted by the Nu Iota, Sigma Theta Tau International Research Committee

4.Send a copy of a final report within 90 days after completing my research to Nu Iota, Sigma Theta Tau International.

5.Acknowledge Sigma Theta Tau International’s support in all presentations, publications, etc.

11.Complete the research within one year of funding. I understand that it is my responsibility to notify Nu Iota, Sigma Theta Tau International in writing if I am unable to complete my research within one year of funding.

By signing below, I understand and agree to adhere to the above-mentioned items. I understand that failure to meet these conditions may result in administrative action including, but not limited to, my becoming ineligible to receive further grants or scholarship funds from Sigma Theta Tau International.

Signature of Principal Investigator

Name of Principal Investigator (please print)

All applications should be submitted electronically to Dr. Stephanie DeBoor, Nu Iota Research Chair.