Western University

Department of Surgery

Internal Research Fund

For Clinical Academics

Application Form

PART 1 – APPLICANT INFORMATION:

Question: / Please complete your response in the table below:
1. Name of Principal Investigator:
2. Division of PI:
3. Date of Appointment of the PI to Western:
4. Please list the name(s) of all co-investigators:
5. End of study form for last SIRF has been submitted to the DOS Main Office: (Yes, No, N/A)

PART 2 – PROJECT INFORMATION:

Question: / Please complete your response in the table below:
6. Title of the Project:
7. Location where the Research Study will take place (e.g. site; laboratory; office)
8. Time Period of Support Being Requested:
9. Does the budget for this application include a request for Graduate Student Support:
10. Total Amount of Money Being Requested*:
11. Does this project involve human participants or animal subjects?
12. Has this project been submitted or received approval by the UWO Health Sciences Research Ethics Board? (if yes, please include a copy of the approval notice with your application)
13. Has this project been submitted or received approval by the UWO Animal User Subcommittee? (if yes, please include a copy of the approval notice with your application)

*(NB: please be sure to append to the application a detailed page outlining a justification of the budget for the funds requested in this application).

PART 3 – GRANT FUNDING:

14. For the Principal Investigator only, please provide information on any other funds applied for and received for all current research projects including funds received from other local and hospital resources. All applications must be indicated, whether or not they have been approved. Please enclose front sheet and all budget sheets with this application of all grants held currently or applied for (please do not submit the whole application). Be sure to note the name of the agency, the title of the project, amount funded/year, and total budget funded. All applications must be indicated, whether or not they have been funded (F) or applied for (A).
15. Describe plans for the future funding for this research project:
16. Please state reason(s) for your request for funds and explain why these cannot be obtained from current research funds or other sources. Indicate clearly how the project in the application is novel or new and how it is/or is not related to other funded projects.
17. Has this study been submitted before to an IRF competition?
18. If yes, please briefly describe below how this project has been modified and/or address the previous reviewers comments (1/2 page maximum):
19. Outline your role in this current proposed project as applicant and the role of each of the co-investigators (if applicable):

PART 4 – OUTLINE OF THE PROPOSED RESEARCH STUDY:

21. Purpose of the Research (1/2 page maximum):
22. Background Information (if appropriate) and Formulation of the objectives & hypothesis (1 page maximum):
23. Experimental plan or design, sample size justification, expected results & potential pitfalls (1 page maximum):
24. Outline the impact that this research will have on the Department of Surgery and on patient care (500 words maximum).

PART 5 – SUPPORTING MATERIAL

The following information should be appended sequentially to this application form:

·  Please attach a mini curriculum vitae (CV) for the principal investigator and all co-applicants describing appointments, publications and abstracts for the last 5 years only (do NOT include lectures, presentations etc.). Each CV should be a maximum of 2 pages.

·  Please attach a detailed budget for the funds requested.

PART 6 – SIGNATURE SECTION

Signature of Applicant / Date
Signature of Chief/Chair of Division / Date
Printed Name of Chief/Chair of Division / Date

PART 7 – SUBMISSION INSTRUCTIONS

Please submit the signed original application and all supporting documentation by PDF electronically to the Department of Surgery Office c/o . The Department of Surgery Research Committee will review the applications.

IRF- Application Form 2