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DUBAI RESIDENCY TRAINING PROGRAM Residency Research Proposal Submission Form Medical Education Department Head of Academic Affairs Centre: Dr. Ashraf Ahmed RRP Administrator: Dr. Mahera AbdulRahman This form is solely for “Residency Research Program” implemented in Dubai Residency Training. Before submitting a formal research application residents are requested to send a research proposal. This will allow the Research Panel to determine the feasibility of the project. Please return your completed form to the Residency Research Program (RRP) Office at firstname.lastname@example.org and please ensure that the email contains you completed Research Proposal. 1.1 Project Title: 1.2 Principal Investigator (PI) Name (Last name, First name MI): Specialty: DHA Staff ID: Phone/mobile Number: Date of Submission: Email: Does your study need to obtain ethics approval at the institution? As Principal Investigator of this study, I assure the RRP that the following statements are true: The information provided in this form is correct. I will seek and obtain prior written approval from the RRP for any substantive modifications in the proposal, including changes in procedures, co-investigators, funding agencies, etc. I will promptly report any unexpected or otherwise significant adverse events or unanticipated problems or incidents that may occur in the course of this study. I will report in writing any significant new findings which develop during the course of this study which may affect the risks and benefits to participation. I will not begin my research until I have received written notification of final IRB approval. I will comply with all RRP requests to report on the status of the study. I will maintain records of this research according to RRP guidelines. If these conditions are not met, I understand that approval of this research could be suspended or terminated. Date This form is solely for “Residency Research Program” implemented in Dubai Residency Training. 1. Research Question/Hypothesis: 2. Aims and Objectives The rationale and need for the research in the UAE community. Consider anticipated applications, potential benefits and impact of your research (priority will be given to enquiries that surpass individual practices and concerns). (Max 200 words) 3. Introduction Outline existing work in the field – not your own. (max 300 words) 4. Methodology (max 500 words) - List test, questionnaires, interview schedules and other evaluation instruments. If None, enter N/A.* - What is the target population? - How many subjects (Adults/pediatrics) total is the study looking for? - What are the inclusion/Exclusion criteria for the study? - Study period? Data of how many years will be included, or subjects for how many years will be followed up, etc.etc. - What are the desired regions for recruited subjects? - Does this study involve collection of patient data information? - Does this study involve collection of tissue/fluid samples? - Are there any risks to the participants of the study? - Resource list 5. Time schedule and Action Plan: Estimated duration of study? This form is solely for “Residency Research Program” implemented in Dubai Residency Training. 6. Brief Research Bibliography (max 20 titles) 7. Curriculum Vitae (including details of Higher Education attendance and degrees/grades attained) Research Academic Advisor As Academic Advisor to the Resident Investigator, I will provide the necessary support and guiding that the resident requires to be given while carrying out his/her research. I also accept responsibility for ensuring that the resident physician complies with Dubai Health Authority policies and regulations regarding the use of human subjects and patient data in research. Advisor’s Name (Last name, First name): Department: Staff ID: Phone Number: Mailing Address: Email: Signature: Date: For Medical Education Department Use Only Comments: This form is solely for “Residency Research Program” implemented in Dubai Residency Training.
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