2017 Gabriella E. Molnar-Swafford Pediatric PM&R Research Grant Application

2017 Gabriella E. Molnar-Swafford Pediatric PM&R Research Grant Application

Application Deadline: May 1, 2017

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: / Status: / Resident, Year
Home Phone: / 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:

Signature Date

Foundation for PM&R 2017 Gabriella E. Molnar-Swafford Pediatric Research Grant Application

2017 Gabriella E. Molnar-Swafford Pediatric PM&R Research Grant Application

Description of Project

Title of project:

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

Specific objectives of project (outline format - 1 page max):

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

Relationship of anticipated results to pediatric rehabilitation (1 page max):

APPENDIX I

Proposed budged (total budget; may include administration costs). 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 previous work and results done by you on this project (list in chronological order; please do not bold or otherwise highlight your name if it appears in this list):

APPENDIX IV - BIBLIOGRAPHY

Publications or presentations pertaining to related work done by you and others on this project (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 2017 Gabriella E. Molnar-Swafford Pediatric Research Grant Application

2017 Gabriella E. Molnar-Swafford Pediatric PM&R Research Grant Application

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 August 1. If IRB application approval has not been received by August 1 you may be asked to resubmit your application in the following grants cycle.

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 . If you have questions, e-mail or call (847) 737-6062.

Foundation for PM&R 2017 Gabriella E. Molnar-Swafford Pediatric Research Grant Application