2015 Request for Proposals – Frailty
Measures
Intent to Apply
1) This document is necessary to determine conflicts of interest and assign reviewers for final proposal.
2) The list of principal investigators and co-investigators cannot be changed after this document has been
submitted.
3) This document must be submitted to apply@tvn-nce.ca by 5 pm ET on Monday, March 23rd, 2015.
Information required
Enter information in this column
Competition A or B?
o Competition A – Knowledge Synthesis Proposal
Highlight the competition that you intend
to apply for by submitting a complete
application package on April 27th 2015.
o Competition B – Implementation Study
Proposal Title
(Maximum 15 words; appropriate for lay
audiences; can be changed on application)
Term of Proposal/Study


Competition A - KS Proposal:
Maximum 6 months
Competition B - Implementation
Study: Maximum 12 months
Estimated Budget


Competition A - KS Proposal:
Maximum $50,000
Competition B - Implementation
Study: Maximum $100,000
Project Leader
Secondary Contact for Project
Leader (Project Manager, Assistant etc.):
Principal Investigator #1
Principal Investigator #2
Surname, First Name:
Email Address:
Daytime Phone Number:
Institution that will receive/administer funds:
Title at Institution/Organization:
Surname, First Name:
Email Address:
Daytime Phone Number:
Visit the TVN website for project team roles definitions (http://www.tvnnce.ca/media/66477/tvn-project-team-roles.pdf)
Surname, First Name:
Email Address:
Institution that will receive/administer funds:
Title at Institution/Organization:
Surname, First Name:
Email Address:
Institution that will receive/administer funds:
Title at Institution/Organization:
1
Principal Investigator #3
Surname, First Name:
Email Address:
Institution/Organization that will receive/administer funds:
Title at Institution/Organization:
Note: Insert rows for additional principal investigators
Co-Investigator #1
Surname, First Name:
Email Address:
Institution/Organization:
Title at Institution/Organization:
Co-Investigator #2
Surname, First Name:
Email Address:
Institution/Organization:
Title at Institution/Organization:
Co-Investigator #3
Surname, First Name:
Email Address:
Institution/Organization
Title at Institution/Organization:
Note: Insert rows for additional co-investigators
Partnerships:
Partner #1:
Please list the partners on this grant and
provide the amount of cash or in-kind
contribution they will be providing.
Partner #2:
Partner #3:
Note: Insert rows for additional partners
Keywords
(Max. 10 words)
Use specific keywords, descriptive
technical terms or methodologies that best
describe the proposal (e.g. Medline
headings):
2
Non-Confidential Project
Summary (Max. 500 words; Highlight
objectives, milestones, deliverables)
TVN Strategic Objective -Highlight ONE strategic objective that this
project most closely aligns with.
TVN Theme --Highlight ONE TVN
research theme that this project most
closely aligns with.
National Scientific Reviewer
#1:
o
o
o
o
o
o
o
o
Matching care to values
Empowering, engaging and supporting patients and their families/caregivers
Improving clinical outcomes
Improving care across the continuum
Improving end-of-life care/advance care planning
Improving acute/critical care
Optimizing community/residential care
Optimizing transitions of care
Provide 3 NATIONAL Scientific Reviewers -- (Minimum of 3 reviewers) Provide
details for 3 suggested, non-conflicted, reviewers for your proposal
Surname, First Name:
Institution:
Email Address:
Phone Number:
National Scientific Reviewer
#2:
National Scientific Reviewer
#3:
International Scientific
Reviewer #1:
Surname, First Name:
Institution:
Email Address:
Phone Number:
Surname, First Name:
Institution:
Email Address:
Phone Number:
Provide 3 INTERNATIONAL Scientific Reviewers (Minimum 3 reviewers) -- Provide
details for 3 suggested, non-conflicted, reviewers for your proposal
Surname, First Name:
3
Institution:
Email Address:
Phone Number:
International Scientific
Reviewer #2:
International Scientific
Reviewer #3:
Surname, First Name:
Institution:
Email Address:
Phone Number:
Surname, First Name:
Institution:
Email Address:
Phone Number:
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