2012 Evidence-Based Practice Project Grant

Save my progress and resume later | resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Your application number (PLEASE include this number on every attachment you upload with your application. If you do not know your number, please email bonniebarnes@DAISYfoundation.org.) *

Date of Application: *

Amount Requested (up to $2,000): *

Study Title: *

SHORT Name of Study Title (50 characters maximum. If this title is different than the one you submitted with your Letter of Intent, please add the word NEW): *

Projected Dates of Project: We realize that you may not have precise dates at this time. Your best guess will suffice.

From: *

To: *

PRINCIPAL INVESTIGATOR/PROJECT TEAM LEADER (PI)

PI - First Name: *

PI - Last Name: *

PI - Credentials: *

PI - Title: *

PI - Email Address: *

PI - Phone Number: *

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

FIRST Team Member/Investigator

1 - First Name:

1 - Last Name:

1 - Credentials:

1 - Title:

1 - Role of Team Member

1 - Email Address:

1 - Phone Number (555 555 5555):

SECOND Team Member/Investigator

2 - First Name:

2 - Last Name:

2 - Credentials:

2 - Title:

2 - Role of Team Member

2 - Email Address:

2 - Phone Number (555 555 5555):

Do you have more than two team members? *

THIRD Team Member/Investigator

3 - First Name:

3 - Last Name:

3 - Credentials:

3 - Title:

3 - Role of Team Member

3 - Email Address:

3 - Phone Number (555 555 5555):

FOURTH Team Member/Investigator

4 - First Name:

4 - Last Name:

4 - Credentials:

4 - Title:

4 - Role of Team Member

4 - Email Address:

4 - Phone Number (555 555 5555):

FIFTH Team Member/Investigator

5 - First Name:

5 - Last Name:

5 - Credentials:

5 - Title:

5 - Role of Team Member

5 - Email Address:

5 - Phone Number (555 555 5555):

AFFILIATED HOSPITAL/INSTITUTION INFORMATION

Institution Name: *

Department/mailstop/PO box, etc.

Street: *

City: *

State: *

Zip Code: *

Is the mailing address for payment of a grant different than this address? *

MAILING ADDRESS FOR PAYMENT OF GRANT

Institution Name: *

Department/mailstop/PO box, etc.

Street: *

City: *

State: *

Zip Code: *

To whom will the check be written if you are approved? (An institution or a fund at your institution, only. Not to an individual.) *

Is the mailing information for your check the same as above? If not, we will collect this information later. *

INSTITUTIONAL OFFICIAL (IO)

If there is an Institutional Official (IO), who should receive copies of funding approval and report requests?

IO - First Name:

IO - Last Name:

IO - Credentials:

IO - Title:

IO - Email Address:

IO - Phone Number:

Have you identified a Project Mentor in your organization or community? *

If you have a Project Mentor, please enter the information below:

Mentor's First Name: *

Mentor's Last Name: *

Mentor's Credentials: *

Mentor's Institution: *

Mentor's Title/Position in institution: *

Mentor's Phone Number: *

Mentor's Email: *

If you have not identified a Mentor, do you want The DAISY Foundation to assist you with your application? *

Are human subjects involved? *

Enter the IRB Identification Number (Please upload your proof of IRB approval at the end of this application):

If IRB approval is pending, on what date is approval anticipated?

Has IRB approval been granted? *

PROPOSAL:

Please complete the following proposal. (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.)

Purpose of the project (Maximum 200 words): *

NOTE ABOVE: Be as specific as you can (Example: Less strong: we want to determine if a patient/family education program works - Stronger: Determine if there is an improvement in patient/family satisfaction with discharge education after implementation of a computer based medication education program).

Background (Maximum 400 words): *

NOTE ABOVE: Describe the current clinical problem that you propose to change. Who is the target audience? (e.g. what group of patients/family/staff will be the focus of the project). Describe how this study/project will benefit cancer or auto-immune disease patients and/or family, in keeping with DAISY Foundation’s stated goal, and how this project addresses the priorities of the J Patrick Barnes Grant program. Cite and summarize evidence (e.g., patient focused data, Quality Improvement/Patient Satisfaction, published research) to support need for a change and also cite evidence to support the initiative you are proposing. Upload a list of references as an appendix to the application.

Describe the proposed change (Maximum 500 words): *

NOTE ABOVE: List step by step how the change will be implemented and how you will evaluate the outcomes of the change. This description should be detailed enough that another hospital could independently replicate your project.

Outcomes (Maximum 400 words): *

NOTE ABOVE: Describe in detail how you will evaluate the outcomes of your initiative. Be as specific as possible on what your outcome measures are (e.g, pre-to-post change in satisfaction score on Item 24 on Press-Ganey survey will be used to evaluate the effectiveness of the intervention). Outcomes can include process outcomes (e.g., how you evaluated that the nurses were actually performing the change in practice) and endpoints (e.g., pre-post evaluation of patient/family satisfaction).

How clinical nurses will be engaged in this study (Maximum 250 words) *

NOTE ABOVE: Describe in detail how clinical/staff nurses will be involved in this study. E.g. in conceptualization, data collection, analysis, reporting. This is a very important component of your proposal.

Timeline: Detail your proposed step-by-step timeline, following this example:

Proposed Study Duration:	Example: 6 months
Time Frame (Weeks)	Task
Example: Weeks 1-4	Prepare all study materials
Example: Weeks 5-10	Recruit participants
Example: Weeks 11-16	Collect data
Example: Weeks 16-22	Data analysis and preparation of final report
Example: Week X	Progress report due to DAISY Foundation
Example: Week Y	Final report due to DAISY Foundation

Your Timeline:

Create a spreadsheet identical to the one above to present your project’s timeline. Please upload your timeline at the end of this application.

Proposed Budget: Funds are available for direct expenses only. Institutional overhead may not be included. Provide budget using the following chart, and describe/provide justification for how you will use the grant funding to support your project (e.g., cost for reproduction of booklets - 500 booklets @ $2/booklet = $1000). If the funding level offered by The DAISY Foundation is not adequate for your project, please email bonniebarnes@DAISYFoundation.org to discuss.

Budget Item Requested	Detail	Cost	Justification: Why this is needed
Example: Reproduction of booklets	500 booklets @ $2.00	$1,000	This is for the family education piece whose effectiveness we are studying
Example: Supplies	Paper and copying	$250
Example: Statistician	To analyze data and prepare final report. 10 hours @$50 per hour	$500	Professional statistical help required to ensure integrity of findings

Your Budget:

Create a spreadsheet identical to the one above to present your project’s budget. Please upload your budget at the end of this application.

DOCUMENTATION – Upload the documents listed below. Your Application Number must be on every page of every document. (Please save your documents using the following simple naming convention for each one you upload: JPB-xxx-A Budget or JPB-xxx-A Timeline, JPB-xxx-A Interview Guide, etc.):

- Timeline

- Budget

- Letter of Agreement (see below)

- Consent Forms

- Interview formats, discussion guides, etc.

- References

- For Research grants, Applicant's CV

- For EBP grants, Applicant's resume or CV

- Proof of IRB approval or letter of exemption (if you have)

Upload here:
Add another document

LETTER OF AGREEMENT: Please copy and paste this onto your institution’s letterhead. Fill in the blanks, print it out and sign it. Your Chief Nursing Officer or other Senior Administrator's signature is also required as an indication of her/his support of your work.

Then scan it into your computer, and upload with this application. Your application is not complete without this document.

I, __________________________________________, Team Leader/Project Leader/Principal Investigator of the project entitled _________________________________________________, commit the following to The DAISY Foundation in return for funding I request of $____________:

That funds will be used only for direct expenses as detailed in the budget provided in my application
That I will inform The DAISY Foundation of the actual start date of this study
That a check for any unused funds will be sent to The DAISY Foundation within 90 days of the project’s completion
That I will communicate in writing to The DAISY Foundation if my project is terminated before completion
That an interim report will be submitted 6 months after funding and a final report submitted within 90 days of the project’s completion including:

- Summary of project objectives

- Summary of findings

- Recommendations as result of study

- Financial summary

That the report of my study may be posted on The DAISY Foundation website, if the Foundation chooses to do so.
That the DAISY Foundation is permitted to use my name/those of my team members and institution and the title and summary of my study in their marketing materials to help promote the grant program.
That I will credit funding from The DAISY Foundation upon publication/presentation of this research.
That The DAISY Foundation may not be held liable for any risk to the subjects of this study.

Signed __________________________ Date_______________

FOR YOUR CHIEF NURSING OFFICER OR OTHER SENIOR ADMINISTRATOR:

I fully support __________________________________, Principal Investigator of the study entitled ___________________________________________________ in her/his implementation of this project.

Furthermore, I attest to the fact that nurse clinicians/staff nurses will be involved in this work, as described in the application.

Signed__________________________________________________

Title____________________________________________________

Date___________________________________________________

Captcha

Please enter the characters you see in this picture:

Characters

This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.
Can't see the image? Click here for an audible version in English.

Save my progress and resume later | resume a previously saved form

Need assistance with this form?