GRANT APPLICATION

ONTARIO RESPIRATORY CARE SOCIETY RESEARCH GRANT APPLICATION

Note: Please refer to Clause 5, Instructions for Submitting Grant Proposals, in the Guidelines for Applicants as you proceed through the Application Form.

1.PRINCIPAL INVESTIGATOR

Name:

Address:

City, Province & Postal Code:

E-mail Address:

Telephone:(Res):(Bus):Fax:

CO-INVESTIGATOR(S) (If more than one co-investigator, please attach information.)

Name:

Address:

City, Province & Postal Code:

E-mail Address:

Telephone:(Res):(Bus):Fax:

2.PROJECT TITLE

Is this a graduate student’s research project?

□ Yes→ is the student an ORCS member? □ Yes □ No

□ No

3.SUMMARY OF FUNDS REQUESTED(Provide details in section 6)

Type of funding requested:Primary $

Supplementary$

A.PERSONNEL$

B.EQUIPMENT$

C.MATERIALS, SUPPLIES & OTHER$

TOTAL AMOUNT REQUESTED $

NOTE: TLA awards are for one year only. Applications for renewal may be made in subsequent years.

4.AFFILIATED INSTITUTION/AGENCY

Institution/Agency Name:

Address:

Contact Person: Bus. Phone:

Name and Mailing Address of Designated Financial Officer:

5.SIGNATURES

The undersigned agree that the general conditions governing the award of a grant, including citizenship or permanent resident status in Canada, as set forth in the "Guidelines for Applicants", apply to any grant made pursuant to this application and are hereby accepted by the applicant and the institution/agency which employs the applicant or with which the applicant is affiliated.

Principal Investigator: ______

Affiliated Institution/Agency Signatures:

Name: ______

(Department Head or Designate)

Title: ______

Signature:______Date:

Name: ______

(Dean of Faculty or Designate)

Title: ______

Signature: ______Date:

Name: ______

(Chief Executive or Designate)

Title: ______

Signature: ______Date:

6.PROPOSED BUDGET

PERSONNEL

List all personnel involved in the project, whether being paid from project funds or not. In the latter case, put N/A in the last two columns on right.

Name / Title & Project Contribution / Time Commitment / Rate of pay per hour / Estimated Expenditure
Hrs. Wk / # of Wks
Subtotal: $

EQUIPMENT

Item / Justification (items which are not self-explanatory) / Estimated
Expenditure
Subtotal: $

MATERIALS, SUPPLIES & OTHER

Item / Justification (items which are not self-explanatory) / Estimated Expenditure
Subtotal: $

TOTAL BUDGET: $

FUNDING REQUESTED FROM ORCS: $

DETAILS OF BUDGET:

Full justification of all budget items is necessary.

7.OTHER FUNDS

For each applicant, list all sources of funding for the project: (1) Current Support; (2) Applied for.

Name(s) of Applicant(s) / Funding Agency; Title of Project; percentage of time or hours per week to be spent on the project / Amount / Status:
Indicate if Held or
Applied For / Support
Period

8. TIMELINE

Please include a schedule (by month and year) for completion of each component of the study, e.g., commencement of study, recruitment of subjects, data collection, data analysis, preparation of results, etc.

9.LAY SUMMARY (suitable for press release).

Please use 10 lines to summarize in general terms the content and methodology of the study and the importance of the research.

10.PERSONAL DATA FORM: To be completed by all named investigators.

Note: If the Principal Investigator or Co-Investigators have a CIHR Common CV, it should be submitted as a separate document as a pdf with the application.

NAME:

ADDRESS:

POSITION:

UNIVERSITY:

EDUCATION INCLUDING CLINICAL TRAINING

Degrees

University or Institution

Field of Study

Yearand Location

RESEARCH AND/OR PROFESSIONAL EXPERIENCE

Dates

Institution

Department

Supervisor

(From - To)

ACADEMIC POSITIONS HELD AND HOSPITAL APPOINTMENTS

Dates

Institution

Department

Position/Title

(From - To)

11.PUBLICATIONS

Total Number (excluding abstracts):

List papers published during the past five years only. Include papers accepted for publication. Abstracts should be listed separately.

12.ABSTRACT OF RESEARCH PROPOSAL: (To be typed in this space only.)

13. SUGGESTED REVIEWERS

Please provide the names and contact information for two (2) suggested external reviewers. Do not include persons with whom the applicants have collaborated during the past three (3) years. Suggested reviewers should not be from the same institution as the investigators.

Name

Address (include institution)

City and ProvincePostal Code

TelephoneFax

E-Mail

Area(s) of Expertise

Name

Address (include institution)

City and ProvincePostal Code

TelephoneFax

E-Mail

Area(s) of Expertise

14.DETAILS OF GRANT PROPOSAL: (Do not exceed 10 pages, single-spaced)

NOTE:Please refer to Clause 5B of the Guidelines for Applicants for a list of items to be included in the detailed proposal.

15.RESEARCH APPLICATION CHECKLIST(Please double-click the appropriate box)

APPLICANTOFFICE

  1. Basic Criteria Met

• ORCS member

• Canadian Citizen/Landed Immigrant

• Ontario Resident

• Eligible Discipline

2.One original and one electronic copy of application, incl.items 3 – 14

3.Summary Information

4.Required Signatures

5.Detailed Budget/Financial Information

6.Timeline

7.Lay Summary

8.CIHR Common CVs or Personal Data Form(s)

9.List(s) of Publications

10.Abstract

11.Detailed Grant Proposal

12.References/Bibliography

13.Documentation of Ethical Clearance for Human Study/AnimalExperimentation/Access toConfidential Records*

*Ethical Clearance must be received no later than sixty (60) days after application deadline.

If this is not possible, please enclose a letter of explanation.

14.Suggested External Reviewers

Communications should be addressed to:

Ontario Respiratory Care Society

The Lung Association – Ontario

18 WynfordDr., Toronto ON M3C 0K8

(416) 864-9911; Fax (416) 864-9916

E-mail:

Revised Sept 2016

16.RESEARCH GRANT PROGRESS REPORT

NAME OF INVESTIGATOR:

DATE OF AWARD: AMOUNT OF AWARD:

POSITION AND DEPARTMENT:

TITLE OF PROJECT:

SUMMARY OF RESEARCH PROGRESS (use additional pages if necessary):

Please append the abstract and timeline from your original proposal and, in your progress report, indicate whether you are adhering to the schedule outlined in your grant application. If not, include an amended timeline in this report.

Is project newsworthy for OLA promotion now? Yes No

If yes, please state how:Press interview:

Television/Radio:

Newspaper article:

Signature of Investigator: ______

17. RESEARCH GRANT FINAL REPORT

See Clause 8A of the Guidelines for Applicants for details of items to be included in this report.

NAME OF INVESTIGATOR:

DATE OF AWARD: AMOUNT OF AWARD:

POSITION AND DEPARTMENT:

TITLE OF PROJECT:

RESULTS OF RESEARCH STUDY:

Attach a one page report summarizing the results of the study. Please include a list and if possible copies of any journal articles, abstracts and presentations resulting from this study.

Publication/Presentation Plans:

Plans for reporting at Lung Association/ORCS seminars/conferences (e.g., Better Breathing) (state year):

Is project newsworthy for OLA promotion now? Yes No

If yes, please state how:Press interview:

Television/Radio:

Newspaper article:

Signature of Investigator: ______