Surgery
Western University
Department of Surgery
Resident Research Grant
Application Form
PART 1 – APPLICANT INFORMATION:
Please complete your response in the table below:
1. Name of Principal Investigator
(Resident):
2. Residency Program:
3. Post Graduate Level:
4. Name of Supervisor(s):
5. Supervisor’s Division:
PART 2 – PROJECT INFORMATION:
Please complete your response in the table below:
6. Title of the Project:
7. Location where the Research Study
will take place (e.g. site; laboratory;
office)
8. Time Period of Support Being
Requested:
9. Total Amount of Money Being
Requested*:
10. Does this project involve human
participants or animal subjects?
11. Has this project been submitted or received approval by the UWO
Health Sciences Research Ethics Board? (if yes, please include a copy of
the approval notice with your application)
12. Has this project been submitted or received approval by the UWO
Animal User Subcommittee? (if yes, please include a copy of the approval
notice with your application)
*(NB: please be sure to append to the application a detailed page outlining a justification of the budget).
PART 3 – SECTION TO BE COMPLETED BY SUPERVISOR
13. Outline your role as the Supervisor:
Schulich School of Medicine & Dentistry, Western University, SJHC, E3-117
London, ON, Canada N6A 4V2 t. 519.663.3349 www.schulich.uwo.ca/surgery
14. For the Principal Investigator only, please provide information on any other funds applied for and received for
all current research projects including funds received from other local and hospital resources. All applications
must be indicated, whether or not they have been approved. Please enclose front sheet and all budget sheets
with this application of all grants held currently or applied for (please do not submit the whole application). Be
sure to note the name of the agency, the title of the project, amount funded/year, and total budget funded. All
applications must be indicated, whether or not they have been funded (F) or applied for (A).
PART 4 – THE FOLLOWING SECTIONS MUST BE COMPLETED BY THE RESIDENT:
OUTLINE OF PROPOSED RESEARCH STUDY
15. Purpose of the Research (1/2 page maximum):
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16. Background Information (if appropriate) and Formulation of the objectives & hypothesis (1 page maximum):
17. Experimental plan or design, sample size justification, expected results & potential pitfalls (1 page maximum):
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18. Please provide a 500 word summary briefly describing your long term career plans and research objectives:
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PART 5 – SUPPORTING MATERIAL
The following information should be appended sequentially to this application form:
 Please provide a letter of recommendation from the Supervisor outlining the research potential of the applicant as
well as the level of support/resources available for the proposed project.
 Please attach a mini curriculum vitae (CV) for the principal investigator, supervisor and co-applicants describing
appointments, publications and abstracts for the last 5 years only (do NOT include lectures, presentations etc.).
Each CV should be a maximum of 2 pages.
 Please attach a detailed budget for the funds requested.
PART 6 – SIGNATURE SECTION
Note: 1) Signature by the Principal Investigator/applicant attests to the fact that all supervisor(s) have reviewed the
application and are in agreement with its content.
2) Signature of the Division Chair/Chief, Residency Program Director as well as the Supervisor attest to the fact that the
applicant is a member of the Clinical Department and the Division supports the proposed project.
Signature of Applicant
Printed Name of Applicant
Date
Signature of Division Chair/Chief
Printed Name of Chief/Chair of Division
Date
Signature of Residency Program Director
Printed Name of Residency Program
Director
Date
Signature of Supervisor
Printed Name of Supervisor
Date
PART 7 – SUBMISSION INSTRUCTIONS
Please submit the signed original application and all supporting documentation by PDF electronically to the Department of
Surgery Office c/o Janice.Sutherland@sjhc.london.on.ca. The Department of Surgery Research Committee will review
the applications.
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