ICTR CAP Clinical & Community Outcomes Research Pilot
2016 Application Documents
(Please contact Kate Judge if you have any questions: 608.262.7125 or kjudge@wisc.edu)
TITLE OF PROJECT
PRINCIPAL INVESTIGATOR INFORMATION
NAME (Last, first, middle)
Amount Requested
$
POSITION/TITLE
HOME DEPARTMENT
TELEPHONE
E-MAIL ADDRESS
Office:
Cell:
GRANT PROGRAM REQUIREMENTS
ICTR Membership required
Are you an ICTR member or have you applied for membership?
No
Yes
HUMAN SUBJECTS
Will you need human subjects approval?
No
Yes
If yes,
Exemption number or IRB approval date: ______________
Pending
SPECIAL CRITERIA (Please indicate which TWO of the following criteria you have chosen; briefly outline how you will fulfill the criteria for those chosen.)
New junior-senior partnership. Please indicate junior PI and senior faculty partner:
Marshfield collaboration. Please indicate who you will be collaborating with:
Interdisciplinary collaboration. Please indicate which schools/colleges are collaborating:
UW-System / UW Extension collaboration. Please indicate which entity/individual you are working with:
ICTR-CAP collaboration. Please indicate which CAP program(s) you are working with (new programs added!):
Science of Community Engagement as a specific aim:
Targeted topic area: Health disparities, Pediatrics, Geriatrics
Have all required letters of collaboration/support been included in proposal? No
Yes
Is this research team a NEW collaboration?
No
Yes
If you answered NO to the question above, were there new members added to the existing research team for this pilot?
Key PERSONNEL (UW or Marshfield faculty and staff)
Name
eRA Commons User Name
STAKEHOLDERS (Community collaborators)
Name
Organization
Organization
Project/Performance Site: Primary Location
Organizational Name:
Street:
City:
County:
State:
Project/Performance Site: Secondary Location (if applicable)
Organizational Name:
Street:
City:
County:
State:
No
Role on Project
Role on Project
Zip:
Zip:
Yes
n/a
ICTR-CAP Clinical & Community Outcomes Research
2016 Pilot Awards Program
SCIENTIFIC ABSTRACT
Provide a concise description of the proposed research written for scientific audiences. 500 word maximum. Your scientific abstract must include: (1) Scientific
rationale; (2) Hypothesis/hypotheses; (3) Research aims and project design; (4) How the project uniquely advances our understanding of the topic; (5) Next
steps for this stream of research (including potential funders who have identified your research topic as a health priority).
ICTR-CAP Clinical & Community Outcomes Research
2016 Pilot Awards Program
COMMUNITY ABSTRACT
500 word maximum. Try not to use any terminology in this abstract but instead tell a story that explains the importance of this research. Your community
abstract must include: (1) Magnitude of the health issue in the state;(2) Goal and objectives—explain the knowledge gap that your research addresses; (3)
Community collaborators/stakeholders involved in your research including who will be engaged and what role they will play; (4) the potential impact of this
stream of research on improving health in Wisconsin and (5) the longer-term policy implications of your research.
From
Through
DETAILED BUDGET FOR 12-MONTH UW ICTR CCOR PILOT PROJECT —DIRECT COSTS ONLY
Key Personnel
NAME
Dollar Amount Requested
Role on
Project
Calendar Academic Summer INST.
months months
months BASE
SALARY
SALARY
FRINGE
TOTAL
PI
SUBTOTALS
$
Collaborator Costs
Consultant or Contractual Costs
Supplies (itemized by category)
Participant Costs
Travel (only for travel necessary to conduct of research)
Other Expenses
TOTAL DIRECT COSTS FOR 12-MONTH PROJECT BUDGET
$