ࡱ> ~}U \'bjbjnn 7baa1*  84^t( F^H^H^H^H^H^H^$;`bl^l^^vF^F^W4*]8wRNY>2^^0^YcTc|*]c*] r\{   l^l^<   ^c          B V:  FRANCES PAYNE BOLTON SCHOOL OF NURSING ALUMNI ASSOCIATION CASE WESTERN RESERVE UNIVERSITY RESEARCH FUND COMMITTEE APPLICATION FOR RESEARCH COMMITTEE FUNDS To: Applicant for FPB Alumni Association Research Award FROM: Helen M. Hurst, DNP, RNC-OB, APRN-CNM Chairperson, Research Fund If your application for a research award is approved, the following are the requirements of accepting this award: To allow a summary of the research to be formulated from the application and/or the abstract on completion, to be published with your name periodically in the alumni magazine/newsletter. To send an abstract of your research to the Alumni Association, c/o Chairperson of the Research Fund. To acknowledge the partial support given to you by the FPB Alumni Association in any public access to this work (i.e. thesis and dissertation acknowledgments, publication of papers and manuscripts, presentations). Please sign below and submit with your application (only one copy of this sheet needed) I agree to comply with the above requirements. Signed: ______________________________ Date: ________________________________ FRANCES PAYNE BOLTON SCHOOL OF NURSING ALUMNI ASSOCIATION CASE WESTERN RESERVE UNIVERSITY APPLICATION FOR RESEARCH STUDY PROPOSAL DIRECTIONS: Please electronically submit a typed copy of application to the chairperson of the Alumni Research Fund Committee; email address is  HYPERLINK "mailto:helenhurst@louisiana.edu" helenhurst@louisiana.edu. Check to see that all questions are answered completely. 1. NAME: ________________________________________ DATE: _______________ 2. ADDRESS: Home: ____________________________ Business: _____________________________ ____________________________ _____________________________ ____________________________ _____________________________ Phone: ____________________________ _____________________________ Email: ____________________________ _____________________________ 3. REPLY TO BE SENT TO HOME_____ OR BUSINESS ADDRESS _____ 4. STATUS: ALUMNI: YEAR(S) _________ PROGRAM ___________________ STUDENT: YEAR _________ PROGRAM ___________________ 4a. ALUMNIS CURRENT EMPLOYER AND POSITION: ___________________________ ____________________________________________________________________________ 4b. STUDENTS MAJOR ADVISOR: ____________________________________________ 5. DEGREES (LIST ALL): ______________________________________________________ 6. TITLE OF STUDY OR PROJECT: ______________________________________________ _____________________________________________________________________________ 7. STATEMENT OF PROBLEM AND PURPOSE/AIMS OF STUDY: (Describe the clinical problem that is the central focus of the study, including scope of problem; state the purpose of the study or specific aims; where appropriate, also state hypothesis (es) or research questions that will guide analysis plan). 8. BRIEF DESCRIPTION OF SAMPLE (Identify size, inclusion and exclusion criteria; provide justification as appropriate): 9. DESCRIPTION OF METHOD AND PROCEDURES (Identify design, describe how sample will be recruited, discuss potential risks to subjects and how these will be handled, discuss sources of data and where appropriate specific tools/methods and their reliability and validity; describe or list steps of procedures to be used in collection of data; address how threats to study validity will be controlled): 10. DESCRIPTION OF DATA ANALYSIS TO BE CONDUCTED (describe plan for storage of data; identify specific analyses to be conducted and relationship to study aims, hypotheses or research questions as appropriate): 11. RELEVANCE/SIGNIFICANCE OF STUDY TO NURSING SCIENCE AND/OR NURSING PRACTICE (Include brief literature support and key citations): 12. PROVIDE BRIEF GRAPHICAL TIMELINE FOR STUDY COMPLETION. 13. STUDENT APPLICANTS SUBMIT STATEMENT FROM MAJOR ADVISOR AFFIRMING THAT STUDY/PROJECT HAS ADVISOR/COMMITTEE FINAL APPROVAL. 14. YOUNG ALUMNI APPLICANTS SUBMIT A STATEMENT OF SUPPORT FROM ADMINISTRATOR/RESEARCHER FOR CONDUCT OF STUDY IN PROPOSED CLINICAL SETTING. 15. ATTACH IRB APPROVAL or PROVIDE ESTIMATED DATE FOR WHEN APPROVAL WILL BE OBTAINED _________________________________________ 16. ATTACH CONFLICT OF INTEREST FORM (login to  HYPERLINK "https://spartacoi.case.edu" https://spartacoi.case.edu to complete training and form) 17. BUDGET AND JUSTIFICATION List all anticipated expenses for completion of study. Identify which specific expenses in budget you would like to be covered by the award (up to $1000), using Protocol for Disbursement of Research Funds as a guide. If travel expenses for data collection are included, please be specific about number of miles to be traveled at the University approved rate. Also if Xerox copies are needed, indicate number of copies and number of pages to justify amount. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ TOTAL BUDGET: ______________ TOTAL AWARD REQUESTED ______________ If total study costs exceed $1000, how do you plan to cover the additional costs in order to assure that you are able to complete the study as planned? __________________________________________________________________________ __________________________________________________________________________ 18. LIST OF KEY REFERENCES CITED IN APPLICATION: REMEMBER TO SAVE IN MICROSOFT WORD VERSION 1997-2003!!! REVIEW CRITERIA ON NEXT PAGE TO BE SURE ALL HAVE BEEN ADDRESSED REVIEW CRITERIA FOR RESEARCH STUDY PROPOSALS Title: Clearly reflects problem and purpose of study. Specific Aims: Clear statement of purpose and/or specific aims. Specific Aims: Well-defined research questions and/or hypotheses for each aim.Design: Clear statement of research design to be used. Design: Appropriateness of design to address purpose, research questions or specific aims.Sample: Well-stated justification of proposed sample size. Sample: Clearly describes inclusion/exclusion criteria and rationale.Sample: Identifies how and where potential participants will be recruited.Measures: Clear description of data/measures be collected, including no. of items and how scored where appropriate.Measures: Clearly describes validity/reliability or sensitivity/specificity of measures where appropriate.Procedures: Protocol clearly describes how and when data will be collected and how well threats to study validity will be controlled.Human Subjects: Identifies, summarizes, and addresses potential risks to participants.Analysis Plan: Appropriateness of plan for stated purpose/ specific aims or research questions and hypotheses.Analysis Plan: Clearly describes how confidentiality of data will be protected during storage and analysis.Significance: Clearly describes significance of study to nursing science and/or nursing practice.Significance: Supports significance of study with literature citations.Timeline: Graphical presentation of timeline for completion of study, including date for obtainment of IRB approval.Budget: Request for funds is appropriate and line item costs are clearly explained and justified.Overall Application: Is well-written and complete.      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