NUS Initiative to Improve Health in Asia

TEMPLATE FOR THE SUBMISSION OF RESEARCH PROPOSALS

Title Page

Name of Principal Investigator: ______

Current Designation: ______

Proposed Area of Research: ______

Title of Research Project: ______

SUBMISSION DOCUMENT CHECKLIST / PLEASE CHECK
(I) / Particulars of Principal Investigator
(II) / Particulars of Collaborators
(III) / Research
(IV) / Schedule
(V) / Cost
(VI) / Any Other Information (Specify & attach if any : Citation, Referee Reports)
(I) PARTICULARS OF PRINCIPAL INVESTIGATOR
Name of Principal Investigator:
Current Designation:
Department/ Division & Faculty/ School, University :
Telephone Number: / Fax Number:
Email Address:
Number of Years
in the University: / End of Tenure with
University (if applicable):
Country of Birth: / Nationality:
Educational Achievement:
Year / Name of Institution
(list Universities & Degrees) / Country
From / To
Employment History:
Year / Name of Past Employers / Job Designations / Country
From / To
(II) PARTICULARS OF COLLABORATORS
Name:
Current Designation:
Department/ Division & Faculty/ School, University :
Telephone Number: / Fax Number:
Email Address:
Number of Years
in the University: / End of Tenure with
University (if applicable):
Country of Birth: / Nationality:
Educational Achievement:
Year / Name of Institution
(list Universities & Degrees) / Country
From / To
Employment History:
Year / Name of Past Employers / Job Designations / Country
From / To
(III) Description of Proposal
Project Title:
Project Objectives:
Potential Impact of Proposed Research on Health in Asia:
Please elaborate on:
(1)How does this project fit in with the objectives of NIHA
(2)How will the findings impact policy formulation in the respective region/country
Technical Description of Project
The description should include the following areas:
(1)Methodology (Background/rationale, Research question/hypothesis, study design, outcomes)
(2)Limitations/Biases/ethical issues and how they will be addressed
(3)Competitors/people working in similar areas that the applicant is aware of
(IV) SCHEDULE
Estimated Start Date: / Estimated Completion Date:
Milestones and Deliverables:
Year 1:
Year 2:
(V) SUMMARY OF PROJECT BUDGET
Item / Year 1 / Year 2 / Total
Manpower
Equipment/ Facilities:
Materials/ Consumables:
Other Operating Expenditure:
Sub-total
Grand Total

DECLARATIONS:

(A) My/ Our project involves the collaboration of the following external organization(s):

1. ______

2. ______

3. ______

(B) My/ Our project involves the use of (please tick)

 Human Subjects;

 Vertebrate Animals

The appropriate ethical clearance from the following committee has been obtained to proceed with this project if it were supported:

Name of Ethics Committee: ______

(C) Conflict of Interest

I, (Insert full name) ______

of (Insert dept. and Organisation) ______

hereby declare a:

REALPOTENTIALPERCEIVED

CONFLICT OF INTERESTCONFLICT OF COMMITMENT

Note: Tick all applicable boxes.

Please provide a brief outline of the nature of the conflict (details may be included privately in a separate confidential envelope if appropriate).

Please detail the arrangements proposed to resolve/manage/ the conflict (attach separately if appropriate).

I, (insert full name)…………………………………………………… hereby agree to:

  • update this disclosure throughout the period of my association with the University on an annual basis or until such time as the conflict ceases to exist.
  • co-operate in the formulation of a “conflict of interest management plan” if required.
  • comply with any conditions or restrictions imposed by the University to manage, mitigate or eliminate any actual, potential or perceived conflict of interest and/or commitment.

(D) I/ We declare that the facts stated in this application and the accompanying information are true and that this is an original proposal.

Name of Applicant(s) / Signature / Date
Principal Investigator:
Collaborator:
Collaborator:
Collaborator:

NIHA, Global Asia Institute | National University of Singapore

University Hall, Lee Kong Chian Wing, #UHL-03-01, 21 Lower Kent Ridge Road |Singapore 119077

Tel: (65) 66011645 | Fax: (65) 67743670 | Website: 1