ICTR-CAP Clinical & Community Outcomes Research (CCOR) Pilot
2018 Application Documents
(Please contact Kate Judgeif you have any questions: 608.262.7125 or )
TITLE OF PROJECTPRINCIPAL INVESTIGATOR INFORMATION
NAME (Last, first, middle) / Amount Requested
$
POSITION/TITLE / HOME DEPARTMENT
TELEPHONE
Office: Cell: / E-MAIL ADDRESS
GRANT PROGRAM REQUIREMENTS
HUMAN SUBJECTS: Will you need human subjects approval? No Yes If yes, Exemption number or IRB approval date: ______Pending
SPECIAL CRITERIA (Please indicate which TWO of the following criteria you have chosen; briefly outline how you will fulfill the criteria for those chosen.)
New junior-senior partnership. Please indicate junior PI and senior faculty partner:
Marshfield collaboration. Please indicate who you will be collaborating with:
Interdisciplinary collaboration. Please indicate which schools/colleges are collaborating:
UW-System / UW Extension collaboration. Please indicate which entity/individual you are working with:
ICTR-CAP collaboration. Please indicate which CAP program(s) you are working with (new programs added!):
Science of Community Engagement as a specific aim:
Targeted topic area: Health Disparities, Pediatrics, Geriatrics
LETTERS OF SUPPORT: Have all required letters of collaboration/support been included in proposal? No Yes
TEAM: Is the assembled research team a new collaboration? No Yes
Or if an established team, were new members added for this proposal? No Yes
CLINICAL TRIAL: Indicate whether the proposed research meets the NIH definition of a clinical trial? No Yes
For definition, see here:
Key PERSONNEL (UW or Marshfield faculty and staf
Name / eRA Commons User Name / Organization / Role on Project
STAKEHOLDERS (Community collaborators/partners)
Name / Organization / Role on Project
Project/Performance Site: Primary Location
Organizational Name:
Street:
City: County: State: Zip:
Project/Performance Site: Secondary Location (if applicable)
Organizational Name:
Street:
City: County: State: Zip:
ICTR-CAP Clinical & Community Outcomes Research
2018 Pilot Awards Program
SCIENTIFIC ABSTRACT
Provide a concise description of the proposed research written for scientific audiences. 500 word maximum. Your scientific abstract must include: (1) Scientific rationale; (2) Hypothesis/hypotheses; (3) Research aims and project design; (4) How the project uniquely advances our understanding of the topic; (5) Next steps for this stream of research (including potential funders who have identified your research topic as a health priority).
ICTR-CAP Clinical & Community Outcomes Research
2018 Pilot Awards Program
COMMUNITY ABSTRACT
500 word maximum. Try not to use any terminology in this abstract but instead tell a story that explains the importance of this research. Your community abstract must include: (1) Magnitude of the health issue in the state;(2) Goal and objectives—explain the knowledge gap that your research addresses; (3) Community collaborators/stakeholders involved in your research including who will be engaged and what role they will play; (4) the potential impact of this stream of research on improving health in Wisconsin and (5) the longer-term policy implications of your research.
DETAILED BUDGET FOR 12-MONTH UW ICTR CCOR PILOT PROJECT —DIRECT COSTS ONLY / From / ThroughKey Personnel / Dollar Amount Requested
NAME / Role on Project / Calendar months / Academic months / Summer months / INST. BASE SALARY / SALARY / FRINGE / TOTAL
PI
SUBTOTALS / $
Collaborator Costs
Consultant or Contractual Costs
Supplies (itemized by category)
Participant Costs
Travel (only for travel necessary to conduct of research)
Other Expenses
TOTAL DIRECT COSTS FOR 12-MONTH PROJECT BUDGET / $