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FOR OFFICIAL USE ONLY Date received: ______________________ ID: _________________________
Part I: Summary of Administrative Information
1. Name of the principal investigator and institutional affiliation:
Last name: First name:
Title: Occupation:
Date of Birth(dd/mm/yyyy) Sex: M / F
Contact detailsFull postal address of the Principal Investigator for official communication. For
telephone and fax numbers, please provide country and area codes.
(Office and institutional address)
(Home)
Telephone (W):
Fax:
Telephone (H):
E-mail-1 (mandatory): E-mail-2: (optional)
2. Co-investigators (There are no limits to the number of co-investigators. Please add more space
or provide additional pages if necessary)
2.1 Last name: First name:
Title: Occupation:
Date of Birth: Sex: M / F Phone:
Email:
2.2 Last name: First name:
Title: Occupation:
Date of Birth: Sex: M / F Phone:
Email:
2.3 Last name: First name:
Title: Occupation:
Date of Birth: Sex: M / F Phone:
Email:
WHO World Alliance for Patient Safety-Small Research Grants: Application form 1
SMALLRESEARCHGRANTSFORPATIENTSAFETY
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Better Knowledge for Safer Care
Project Summary
Project title
Principal investigator(s) and contactdetails
Co investigators and affiliatedinstitutions
Project Manager and contact details
Administering institution, country
Collaborating institutions
Project location, city and country
Ethical review body
Main funding agency
Other funding agency (if any)
Project Budget
Project Duration
Estimate start date
Estimate finish date
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Better Knowledge for Safer Care
PART II: RESEARCH STUDY PROPOSAL
1. Title of the project:
2. Project Summary (This should be about 350 word and self contained as an abstract)
3. Background and Rationale: (This includes literature review of previous studies on the subject;and rationale of the study by stating the problem and its public health importance. Please include
references as needed)
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4. Study goal, objectives and main research questions:
4.1 Goal and objectives: (state the goal and objectives you need to achieve)
4.2 Research questions: (state the specific research questions that will enabling the achievement ofeach objective that will finally lead to achievement of the goal)
1.
2.
3.
4.
5.
(more, if any)
4.3 Secondary objectives/ questions: (These are subsidiary objectives that could be studied during
the course of the project but are not the main objectives of the study, they are optional)
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5. Methods
5.1 Setting: (Describe the area or setting where the study will be conducted)
5.2 Study design: (Describe the type of study design eg cross-sectional, case-control study, etc..)
5.3 Study subjects: (State clearly eligibility and exclusion criteria of the study subjects)
5.4 Sample size and sampling techniques: (Describe the input criteria for sample size estimationand the sampling technique that will be used in order to obtain a representative sample for your
target population.)
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5.5 Data Collection methods, instruments used, measurements
(Describe the instruments/tools to be used for data collection (questionnaire,observation recording
form, etc..), and studied variables included in these instruments, as well as the methods used to test
for the validity and reliability of the instrument)
5.5.1Study definitions (e.g. case definition)
5.5.2 Main variables and measures (including dependent and independent variables and
covariates)
5.5.3 Instruments/tools (to be used for data collection and studied variables included in theseinstruments. If applicable, please attach a copy of the questionnaire or tools to be used and ensure
that they are appropriately referenced.)
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5.5.4 Techiques/ methods (used to test the applicability, validity and reliability of the instrument.
Please indicate appropriate references if using already validated tools)
5.5.6 Data management and analysis plan: (Describe the analysis plan and statistical packages
to be used)
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6. Expected direct products (outputs)
7. Implications of study results on patient safety practice and/or interventions
(Expected results and potential contribution of the project to patient safety)
8. Dissemination of results and publications plan
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9. Ethical Considerations:
9.1 Ethical considerations (Illustrate that your research proposal is acceptbly safe, respect therights of participants, data treated with confidentiality etc. Discuss any other issues that are likely to
raise ethical concerns and how you will address them.)
9.2 Informed consent form (If applicable, discuss the issues that are likely to raise ethical
concerns and describe how the investigator(s) plan to obtain informed consent from the research
participants. If needed, please attach extra documents)
9.3 Institutional ethical clearance
o Do you have an ethical review board in your institution? Yes No
o Institutional ethical clearance has been obtained for the study: Yes No
(In case there is no institutional ethical review board, the clearance of a national ethical review
body or clearance of the Ministry of Health could be accepted. )
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10. Bibliographic references (List relevance references including journal articles)
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Better Knowledge for Safer Care
Part III- A: Project Management and Organisation
11. Project plan and duration (provide an outline of the project plan. Indicate when the projectwill commence and specify the time that each phase of the project is likely to take.
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12. Timelines:(Please indicate the activities to be conducted and mark the corresponding month on the Gantt chart. The project should belimited to 18 months at the most)
Key milestones MONTH (from project commencement)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Progress report
(required)
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12. Timelines:(Please indicate the activities to be conducted and mark the corresponding month on the Gantt chart. The project should be
limited to 18 months at the most)
Key milestones MONTH (from project commencement)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Final report
(required)
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Better Knowledge for Safer Care
*Not exceeding $US 25,000. Please consult the Conditions of Grants foradmissible expenses.**unit cost of each item should be accurately given to allow proper budget evaluation.
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13. Budget* (The budget section should contain a detailed breakdown of the funds requested for,
along with a justification for each item)
Budget Breakdown Unit cost
($US)**
Budget
($US)
Other
Sources
($US)
Total
GRAND TOTAL
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13.1 Budget justification (Discuss and justify the costs stated in the budget table. State the value of
the project costs in local currency and how they compared with other similar projects conducted inthe same areas).
14. Risks and assumptions (Discuss the difficulties that the investigators anticipate in the courseof completing the projects within the time frame and budget and explain possible solutions to deal
with these difficulties).
15. Annexes: (Please list data collection instruments or any other related documents that you wishto attach here and attach them to the application)
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Part III- B: Project Management and Organisation
16. Project team and project management (List project team members both academic and
administrative staff and describe their role and responsibilityies. Use the format: Name, Position,
affiliated organisation, role in the project )
17. Networks/ collaborations (if applicable) (describe the collaboration established or
implemented)
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18. Other funding agency
Is this project part of the study funded by another funding agency: Yes No(If yes, please specify the agency and available funds)
19. Other information (Provide other relevant information. If needed, please attach relevantdocuments)
19.1 Collaboration with other scientists or research institutions
19.2 Links to other projects etc. (Indicate if this study is linked to or part of other projects/studies. If
so, please explain.)
19.3 Other research activities of the principal investigator -should list all current research projects
that he/she is involved in, the source of funding of those projects, the duration of those projects and
the percentage of time spent on each.
19.4 Financing and Insurance (Illustrate that the institution has the ability and capacity to
administer the grant).
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