Centre for Innovation

BloodTechNet Competition2016

ApplicationForm

  1. Applicant Information

Primary Applicant: [First and last name]

Profession: [Examples include Medicine, Nursing, Medical Laboratory Science, Research, Administration, Human Resources, Communications]

Institution/Organization:

Position:

Mailing address:

Telephone:

Email:

  1. Project Summary

Project Title:

Project Summary:

Please provide a lay summaryin this text box describing the proposed project and its objectives. Use non-technical, jargon-free language. If the project is approved, this lay summary may be published on Canadian Blood Services’ website and used for program promotion. 200 word maximum.

Measuring Impact:

Describe how the team will measure the impact of the educational tool that will be developed through this project. For example, identify metrics that will be collected to see how the educational tools may be used.200 word maximum.
  1. Project Collaborators

Please list the collaborators who will be part of the project team.Add more Collaborator sections as needed.

Collaborator 1: [First and last name]

Profession:

Institution/Organization:

Position:

Role in the project:

Relevance of expertise/skills to project’s objectives:

Collaborator 2: [First and last name]

Profession:

Institution/Organization:

Position:

Role in the project:

Relevance of expertise/skills to project’s objectives:

Collaborator 3: [First and last name]

Profession:

Institution/Organization:

Position:

Role in the project:

Relevance of expertise/skills to project’s objectives:

  1. Project Proposal

Please provide a project proposal in this text box that includes:
  • Purpose and context: What issue is being addressed, its significance and any relevant background.
  • Approach: How will you accomplish the project’s objectives?
  • Dissemination: How will you reach your target audience?
  • Project schedule (Gantt chart): Provide key project activities, milestones and deliverables and identify when you anticipate completing these.
  • Identify challenges that may hinder your project’s success and ways you may mitigate these.
The project proposal may not exceed two pages total.
  1. Project Budget

Please select one budget category for the project.

☐Small <$10,000

☐Medium $10 – 25,000

☐Large $25 – 50,000

Budget details:

Budget Amount / How will it be used?
Total Budget:

Budget notes (optional):

Please add any other budgetary notes as needed. List additional sources of funding if applicable.
  1. Conflict of Interest

Does the applicant or collaborators have any conflict of interest with this application?

☐Yes ☐No

If yes, please provide details:

  1. Applicant signature and date

______

SignatureDate

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