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2012 Letter of Intent

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Date of Letter of Intent Submission: *

Name of Proposed Study: *

SHORT Name of Proposed Study (50 characters maximum): *

How did you learn about the J. Patrick Barnes Grant program? *

PROJECT TEAM LEADER

PL - First Name: *

PL - Last Name: *

PL - Credentials: *

PL - Email Address: *

PL - Phone Number: *

IF THERE ARE ADD'L PEOPLE ON YOUR TEAM - YOU MAY LIST UP TO 5 TOTAL

FIRST Team Member

1 - First Name:

1 - Last Name:

1 - Email Address:

1 - Phone Number:

1 - Role in Study:

SECOND Team Member

2 - First Name:

2 - Last Name:

2 - Email Address:

2 - Phone Number:

2 - Role in Study:

Do you have more than two team members? *

THIRD Team Member

3 - First Name:

3 - Last Name:

3 - Email Address:

3 - Phone Number:

3 - Role in Study:

FOURTH Team Member

4 - First Name:

4 - Last Name:

4 - Email Address:

4 - Phone Number:

4 - Role in Study:

FIFTH Team Member

5 - First Name:

5 - Last Name:

5 - Email Address:

5 - Phone Number:

5 - Role in Study:

INSTITUTION INFORMATION

Institution Name: *

Street: *

City: *

State: *

Zip Code: *

Will the application be for: *

STUDY PROPOSAL INFORMATION

(To determine the number of words you are using, type in a Word document first and use word count. Then copy/paste into the form below.)

Background: (Maximum 250 words) *

Purpose of Study/Description of how this study/project will benefit cancer or auto-immune disease patients and/or family, in keeping with DAISY Foundation's stated goal: (Maximum 200 words) *

General outline of study: Methods/Sample/Setting/Procedure: (Maximum 250 words) *

Specific description of how clinical nurses will be involved in the study (e.g. conceptualization, data collection, analysis, reporting): (Maximum 250 words) *

Do you have a mentor for your study? *

If Applicant has a Mentor, please enter the information below:

Mentor's First Name: *

Mentor's Last Name: *

Mentor's Credentials: *

Mentor's Email: *

Mentor's Phone Number: *

Mentor's Current Position: *

Would you like the DAISY Foundation to contact you about providing a Mentor? *

Do you plan to apply to DAISY for subsequent funding to help you disseminate your findings? *

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