8/14/2019 Small Grants PS Application form

1/18

Better Knowledge for Safer Care

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

8/14/2019 Small Grants PS Application form

2/18

ID:

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

WHO World Alliance for Patient Safety-Small Research Grants: Application form 2

8/14/2019 Small Grants PS Application form

3/18

ID:

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)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 3

8/14/2019 Small Grants PS Application form

4/18

ID:

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)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 4

8/14/2019 Small Grants PS Application form

5/18

ID:

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.)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 5

8/14/2019 Small Grants PS Application form

6/18

ID:

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.)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 6

8/14/2019 Small Grants PS Application form

7/18

ID:

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)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 7

8/14/2019 Small Grants PS Application form

8/18

ID:

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

WHO World Alliance for Patient Safety-Small Research Grants: Application form 8

8/14/2019 Small Grants PS Application form

9/18

ID:

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. )

WHO World Alliance for Patient Safety-Small Research Grants: Application form 9

8/14/2019 Small Grants PS Application form

10/18

ID:

10. Bibliographic references (List relevance references including journal articles)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 10

8/14/2019 Small Grants PS Application form

11/18

ID:

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.

WHO World Alliance for Patient Safety-Small Research Grants: Application form 11

8/14/2019 Small Grants PS Application form

12/18

ID:

Better Knowledge for Safer Care

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)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 1

8/14/2019 Small Grants PS Application form

13/18

ID:

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)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 1

8/14/2019 Small Grants PS Application form

14/18

ID:

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.

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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

14

8/14/2019 Small Grants PS Application form

15/18

ID:WHO World Alliance for Patient Safety-Small Research Grants: Application form 15

8/14/2019 Small Grants PS Application form

16/18

ID:

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)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 16

8/14/2019 Small Grants PS Application form

17/18

ID:

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)

WHO World Alliance for Patient Safety-Small Research Grants: Application form 17

8/14/2019 Small Grants PS Application form

18/18

ID

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).

WHO World Alliance for Patient Safety Small Research Grants: Application form 18