AAP Resident Research Grant Application 2016 APPLICATION INSTRUCTIONS Please complete all fields within the application. Also, please pay close attention to the word limits for specific section. If you exceed the word limits your response will be truncated at the word limit and scored accordingly. If you have questions about this application, send an email to Jeannine Hess at email@example.com or call 800/433-9016, ext. 7876. PERSONAL INFORMATION Full Name: Address: City: State: Zip: Home Telephone: Primary E-mail address: Date of Birth: Place of Birth: PROJECT TITLE Title of Research Project: EDUCATION INFORMATION Medical School/Date of Graduation: Training Program Name: Training Program City & State: Project Mentor Name: *Mentor must be a good-standing member of the AAP Project Mentor Address & Telephone: Program Director Name: Program Director Address & Telephone: Department Chairperson Name: Department Chairperson Address & Telephone: PEDIATRIC TRAINING PGY-1- Hospital Name, City (Dates From – To): PGY–2- Hospital Name, City(Dates From – To): PGY-3- Housing Name, City(Dates From – To): PGY-4 - Hospital Name, City(Dates From – To): PGY-5 - Hospital Name, City(Dates From – To): Anticipated Date of Completion of Your Residency Program: GRANT INFORMATION Proposals involving human subjects require Institutional Review Board (IRB) approval. YES Has your IRB approved this proposal? Currently Under Review NO Not Applicable (no human subjects) Proposed Starting Date of Research: Anticipated Date of Completion: GRANT INFORMATION The $3,000 check ($2,000 grant award plus $1,000 travel stipend) will be made payable to the name of the institution. The grant must be used specifically for this project. Funds from grant award should not be used for computer equipment. No indirect charges will be paid to the institution. Please issue the check to: Institution Name _______________________________________________________ Institution Address _____________________________________________________ City, State and Zip _____________________________________________________ Institution Telephone ____________________________________________________ PROPOSED RESEARCH I. OVEALL GOALS, SPECIFIC AIMS: [Please limit response to 500 words or less] II. HYPOTHESIS – RESEARCH QUESTION AND REASON FOR STUDY: [Please limit response to 300 words or less] III. METHODOLOGY AND RATIONALE: (Indicate what components of the research, such as data collection or analysis, you will be performing directly. If a survey will be used, please include a list of key questions.) [Please limit response to 750 words or less] IV. . BIBLIOGRAPHY: V. BUDGET: (Submit a basic budget that outlines how the grant money will be used. If your budget exceeds $2,000, where will additional funding come from? Please describe.) VI. REVELANCE TO PROFESSIONAL CAREER: (Describe how you selected this topic for study and how this proposed project fits into your career plans. Include relevant research, clinical experience, and how the knowledge and skills you will learn will contribute to your future professional goals.) How did you hear about this program? Internet / AAP website Department Chairperson Program Director Program Coordinator Chapter Executive Director “What’s New” Email from AAP Other Residents Other ____________________________________________________________ *** REMINDER *** ALL FIELDS OF THE RESIDENT RESEARCH GRANT APPLICATION ARE REQUIRED. DO NOT EXCEED WORD LIMITS. DEADLINE: February 29, 2016 Email completed application to firstname.lastname@example.org along with ALL supporting documents/letters of support.