(Appendix F)PAGE 1 OF 9

AHSC AFP INNOVATION FUND 2012– 2013

APPLICATION FORM

*Please note that this HAHSO application form supersedes the application form (Form 2) in the IFPOC guidelines.

PROJECT TITLE:

______

______

PROJECT LEAD/PRINCIPAL INVESTIGATOR:

NAME: ______SIGNATURE: ______

TITLE: ______

GOVERNANCE ORGANIZATION: HAHSO

PRACTICE PLAN OF PARTICIPATING PHYSICIAN WHO IS THE PROJECT LEAD:

ANESTHESIA

FAMILY MEDICINE

MEDICINE

OBSTETRICS & GYNECOLOGY

ONCOLOGY

PEDIATRICS

PSYCHIATRY

SURGERY

ADDRESS: ______

EMAIL: ______

TELEPHONE: ______

FAX: ______

PHYSICIAN ASSOCIATION PRESIDENT SIGNATURE: ______

DATE: ______

The completed application package will include the following documents (in the order specified below) as ONE .pdf file using the principal investigator(s) name as the file name:

1.Completed Application Form (includes budget on page 7)

2.Narrative Proposal (5 page maximum. Proposals which exceed the 5-page limit will be automatically rejected).

Do not submit CVs, publications or other unnecessary information.

DUE DATE: Monday, November 5, 2012; 1700 hours

(Appendix F)

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 2OF 9

APPLICATION FORM

PLAIN LANGUAGE DESCRIPTION:

Use the space below (no more than 100 words) to describe the proposed project using non-technical language. Please emphasize the research question and its importance to health care delivery. This summary description may be used, in whole or in part, in press releases or similar communication material if the award is approved. Ensure the description can be understood by individuals outside of the research field.

______

WHAT IS THE MAIN RESEARCH QUESTION/HYPOTHESIS UNDERLYING THIS PROPOSAL?

______

DESCRIBE HOW THIS RESEARCH WILL INFLUENCE THE HEALTHCARE SYSTEM AND/OR DIRECT PATIENT CARE?(150 words):

______

PRINCIPAL INVESTIGATOR/CO-PRINCIPAL INVESTIGATOR(must be an AFP participating physician):

NAME / TITLE / INSTITUTIONAL AFFILIATION

CO-INVESTIGATOR(S) (doesn’t need to be a participating physician or MD):

NAME / TITLE / INSTITUTIONAL AFFILIATION
1.
2.
3.
4.
5.

(Appendix F)

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 3 OF 9

APPLICATION FORM

DURATION OF PROJECT: One Year Two Years

AMOUNT REQUESTED FROM INNOVATION FUND: YEAR 1 $ ______YEAR 2 $______

Maximum Funding: $100,000 per year for two years

MULTI SITE PROJECTS (list collaborative institutions):

What are the names of the other institutions? If AFP funds will be transferred to another institution, please explain (100 words):

1.______Applied for Innovation Funding? Y N

2.______Applied for Innovation Funding? Y N

3.______Applied for Innovation Funding? Y N

4.______Applied for Innovation Funding? Y N

5.______Applied for Innovation Funding? Y N

How many additional institutions (beyond this one) must receive funding in order for the project to proceed? ______

Which (specify, if applicable) institution(s) must participate in order for the project to proceed? ______

______

Is this proposal:
An extension of a previous AFP funded project?Y N
Supplemental funding for existing project? Y N
Supported financially by another institution? Y N
If yes, please specify by source and amount received or requested
Source:
Title of Award:
Year One: $ Year Two: $ / Source:
Title of Award:
Year One: $ Year Two: $

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(Appendix F)

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 4OF 9

APPLICATION FORM

Section II: Innovation Project Focus
A. Please provide Five keywords to describe your project:
1.
2. / 3.
4. / 5.
C. Innovation Project Focus (Check all that Apply)
1. Aging/ Geriatrics
2. Allergy/ Immunology
3. Anticoagulants/ Thromboembolism
4. Arrhythmias
5. Asthma
7. Bone Disease
8. Breast Cancer
9. Cardiomyopathy/ Myocarditis
10. Cardiovascular Diseases
11. Child Health
12. Colorectal Cancer
13. Coronary Disease
14. Critical Care
15. Dermatology
16. Diabetes
17. Diet/ Nutrition
18. Emergency Medicine
19. Endocrinology / 20. Gastroenterology
21. Genetics
22. Global Health
23. HIV/AIDS
24. Heart Failure
25. Haematology
26. Hypertension
27. Immunology
28. Infectious Diseases
29. Influenza
30. Kidney Diseases
31. Leukemia/ Lymphoma
32. Liver Disease
33. Medical Ethics
34. Multiple Sclerosis
35. Neonatal Medicine
36. Neurological Disease
37. Obesity
38. Oncology
39. Osteoporosis/ Bone Disease / 40. Pain and Palliative Care
41. Parkinson’s Disease
42. Pregnancy
43. Prostate Disease
44. Psychiatry
45. Pulmonary Disease
46. Rheumatic Disease
47. Swine Flu
48. Seizures
49. Stroke
50. Surgery
51. Transplantation
52. Tuberculosis
53. Vaccines
54. Viral Diseases
55. Women’s Health
56. Other (Please Specify)
D. Innovation Project Methodology (Check all that Apply )
1. Case Study
2. Cross-Sectional Study
3. Critical Appraisal
3. Epidemiology
4. Ethics
5. Experiment
6. Evaluation
7. Evidence-Based Medicine
8. Health Care Delivery
9. Health Economics
10. Health Policy / 10. Health Services Research Applied Methods
11. Information Technology
12. Longitudinal Study
13. Management Sciences
14. Medical Education and Training
15. Meta Analysis
16. Psychology
17. Qualitative Research / 18. Quality and Safety
19. Outcomes Research
20. Sociology
21. Statistics, Biometrics and Econometrics
22. Surveys
23. Trials
24. Other (Please Specify)
E. Projected Outcomes (Check all that Apply)
1. Change Patient Behaviour
2. Change Physician-Specialist Relations
3. Create Guidelines and Best Practices
4. Encourage Knowledge Transfer / 5. Improve Continuity of Care
6. Improve Quality of Care
7. Improve Patient Safety
8. Support collaboration with community hospitals, LHINS and other services / 9. Increase remote access to care
10. Promote more efficient health care delivery
11. Other (Please Specify)

(Appendix F)

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 5 OF 9

APPLICATION FORM

  1. PROPOSAL(up to 5 pages and NO appendices or other attachments):

The proposal should not exceed 5 typed pages. A minimum margin of 2 cm (3/4 inch) around each page is mandatory. A font size of 12 point, black ink should be used, with 6 lines of text per inch, and no condensed type or spacing. Text should appear on one side of the paper only. Proposals exceeding the specified page limit will not be accepted.

The proposal should include the following elements:

  1. A concise description of:
  • The current state of the research field and justification of the research questions/hypotheses under study
  • The nature of the proposed research or innovation, for example:
  • Quality initiative
  • Prospective randomized control trial
  • Prospective control trial
  • Prospective pre-post intervention study
  • Observational study
  • Chart review
  • Literature review
  • Demonstration project
  • Patient registry
  • A clear statement of the research questions/hypotheses
  • A description of research strategy, methodology, research team and statistical analyses
  • A description of the innovation and the relevance of the research to health care; for example:
  • Describe how the research is innovative
  • What issue does the proposed research address within the eligible areas of scope?
  • What evidence is there that this issue is important from a broad system perspective?
  • How will the research results be used and to whom will they be applicable?
  • How broadly relevant will they be? Will the results of the project potentially lead to a sustainable change in practice, process and/or education?
  • What are the plans or opportunities for knowledge translation or dissemination of the project outcomes and to improve health care in Ontario?
  • To what extent does this proposal support leadership in the dissemination of knowledge across the healthcare system?

(Appendix F)

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 6 OF 9

APPLICATION FORM

  1. Metrics to evaluate outcome of the project (should be 1/3 to 1/2 page)

This section should outline in detail what the anticipated outcomes would be and how the outcomes will be measured. It should provide a list of measurable milestones (outcomes) upon which the team will periodically report (at the end of the project if a one-year project, and annually if the funding is for two years). How will the funders determine if the project was successful?

  1. Impact:

What is the expected benefit and how will it be measured?

  1. Timeline

This section should provide a target start date, target completion dates for significant steps (milestones) leading to the proposed outcomes, and target finish date for the project. For example:

Timeline / Milestone Targets (brief overview description)
6 months
1 year
2 years (if relevant)
  1. Additional Project Funding

This section should elaborate on any supplemental funding for the proposed project.

Indicate whether such supplemental funding is currently available or is contingent upon approval of grant application. Specify the amount and source of funding from the other funding agency.

(Appendix F)

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 7 OF 9

APPLICATION FORM

  1. Budget Breakdown (up to one page)

A brief description and justification of all requested budget expenditures should be attached with sufficient detail to allow for an assessment of the eligibility of these budget expenditures, including position, title, FTE and benefit costs, salary for physicians and research, health professional and administrative staff.

The budget breakdown should also specify the contributions (cash, in-kind) of any other funders/contributors.

Budget Details / Year 1 / Year 2
(if applicable)
  1. PERSONNEL/POSITION TITLE
/ FTE / ANNUAL
SALARY / ANNUAL
BENEFITS
Total Personnel / $0 / $0
  1. SUPPLIES (itemize components)

Total Supplies / $0 / $0
  1. EQUIPMENT (provide justification for equipment purchases of$2000)

Total Equipment / $0 / $0
  1. OTHER EXPENSES (itemize accounting services, space rental, lab service, diagnostics, patient reimbursement, etc.)

Total Other Expenses / $0 / $0
TOTAL AMOUNT REQUESTED / $0 / $0

Provide additional budget justification to support expenditures if not referenced in methodology and work plan section

(Appendix F)

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 8 OF 9

APPLICATION FORM

Any resource implications for the Hospital or the University? YesNo

If yes, describe: ______

______

Host Institution Responsible for Administration of Grant:

Hamilton Health Sciences

McMasterUniversity

St. Joseph’s Healthcare Hamilton

Relevant approvals to be sought after notification of grant approval and funding by HAHSO and IFPOC on behalf of MOHLTC:

Human Ethics

Animal Ethics

Patient Consent

Bio-Hazardous Materials

Health Physics

AHSC AFP INNOVATION FUND 2012 – 2013PAGE 9OF 9

APPLICATION FORM

To Be Completed Subsequent to Submission of Proposal to HAHSO

Approval by:

HAHSO Board

Funding Allocated by Year

2012/13$______

2013/14$______

______

Board ChairDate

Institutional Sign-Off (to be completed after approval of application by HAHSO Board):

Hospitals:

______

Hamilton Health SciencesNameTitle

and/or

______

St. Joseph’s Healthcare HamiltonNameTitle

University:

______

Faculty of Health SciencesNameTitle

McMaster University

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