Air Medical Physician Association
Seed Grant Application
AMPA SEED GRANT RESEARCH AWARD
Project Title:
Principal Investigator (Student/Trainee):
Name:
Medical Specialty:
Phone Number of PI:
Email Address of PI:
Name of Institution:
Preferred Mailing Address of PI:
AMPA Active Member Research Advisor/Mentor:
Name:
Medical Specialty:
Phone Number of Advisor/Mentor:
Email Address of Advisor/Mentor:
Name of Institution:
Preferred Mailing Address of Advisor/Mentor:
Dept/Practice Manager:
Anticipated Project Start Date:
Anticipated Project Completion Date:
Total Funds Requested:
_______________________________________________________________________
Principal Investigator Signature
Date
_______________________________________________________________________
Research Advisor/Mentor Signature
Date
_______________________________________________________________________
Department Chair Signature
Date
Date Submitted ____________
Applications should be submitted 1) via email to ppeter1111@aol.com, and 2) a hard copy mailed to:
AMPA Seed Grant Application
c/o Patricia Petersen
951 East Montana Vista Lane
Salt Lake City, Utah 84124
Proposals are due no later than March 25, 2016
Proposals will be reviewed four weeks later
Award Announcement April, 2016
AMPA Application for
Seed Grant Research Award
1.
SIGNIFICANCE AND RELEVANCE OF THE RESEARCH
Briefly sketch the background of this proposal (preliminary studies, if any), critically evaluate existing
knowledge (literature reviewed), and specifically identify gaps the research is intended to fill.
2. HYPOTHESIS
Briefly outline the specific questions that are to be answered by the study. This should include
predictions as to the findings (hypotheses) and justifications for the predictions.
3. MATERIALS AND METHODS
Describe the design and procedures to be used to accomplish the specific aims of the project, the
protocols to be used, and timetable for the study. Provide, where appropriate, specifics about the
population of cases from which the sample will be selected and explain the criteria and process for
selection, plans for statistical analysis (please include sample size calculations), and facilities and
equipment utilized.
4. SUMMARY
Provide a one paragraph abstract of the research plan. The summary is meant to serve as a succinct and
accurate description of the proposed work and its impact on the health care field.
5. REFERENCES
Provide complete literature reference for each citation given in this proposal.
BUDGET
Personnel
Position Title
Hours/
Week
Cost to
Project
# Items
Cost per
item
TOTAL
# Items
Cost per
item
TOTAL
TOTAL:
Supplies
Item Description
TOTAL:
Equipment/Capital
Item Description
TOTAL:
Patient Care Costs
Description
TOTAL
TOTAL:
Other Costs (Itemize)
Description
TOTAL
TOTAL:
TOTAL BUDGET
6. OTHER CURRENT OR ANTICIPATED SUPPORT FOR THIS PROJECT
List current grant of Hospital supports. Also note any pending proposals related to this project. Explain
how this project might lead to funding of a proposal for a larger study (utilizing this project’s data) to a
regional or national granting agency.
7. PROTECTION OF HUMAN SUBJECTS
A.
This project has been submitted to the Institutional Review Board (IRB):
_____ Has been approved
_____ Is exempt from review
B. This project has not been submitted to the Institutional Review Board:
______ But will be submitted
______ Because it is exempt from review
Questions? Contact Pat Petersen via e-mail at Ppeter1111@aol.com