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Hartford Hospital Research Application by HC120919222448


									Hartford Healthcare Research Application
Supplemental Information Form
PI:                             Project #

Part I to aid Research Committee in consideration of application.
1.    Please indicate your role in Hartford Healthcare
      Attending Physician
      Other Health provider
      Senior Scientist or Other Researcher
      Resident or Fellow
      Medical Student
      Other _________________
   Which HHC partner __________________________

2. If applying for Medical Staff funding (Small Grant or Patient Safety/Quality

   Are you or one of your research team a member of Medical Staff?
                                                No        Yes
   If a co-PI who? __________________________
3.     Which of the following is applicable to your project? (Please check all
       that apply and complete the appropriate section below.)
   A. Pilot study (to collect preliminary data)
   B. Feasibility study (to test logistics of study)
   C. Supplemental funds
   D. Funding for statistics or data base only
   E. Educational Requirement
   F. Are you a New Investigator? Yes               No
       (i.e., Have you ever received Hartford Hospital funding or funding from
       external source for a study?)
   If A. or B. (Pilot or Feasibility Study):
   Is this pilot being done prior to application for research funding?
   Yes     No
     Name of agency/foundation
     Date of proposed submission
If C. Supplemental funds:
Original Enrollment goal:          Enrolled to date:
Has there been a subsequent power calculation? Yes        No
Results to date (please provide brief description):

Need for funds (please justify request for additional funding)

If D. Funding for statistics or data base only:
Will work be done at Hartford Hospital? Yes     No
Have you discussed design/budget with Senior Scientist and/or member of
   Database staff in the Research Program?
   Yes      No
Person(s) contacted:

If E. Educational Requirement:
Are you in a training program at Hartford Hospital? Yes          No   If yes,
    Fellow     Resident     Med Student    Other

Date(s) of Hartford Hospital Training

How will this study be completed if it extends beyond your educational

Name of Mentor

Please list/describe other sources of support
Part II for Research Administration during implementation of your project if
approved by the Committee for funding

Projects receiving internal funding will no longer be awarded the full amount of
the approved budget at the time of project approval. The award contract will
specify an initial amount and projects will be reviewed again when additional
funds required. If progress has been satisfactory, further funds will be

Please provide the following information, or if already an integral part of project
protocol, please provide page or section number.

1. Project Timeline:

2. Define goals for first phase (until additional funding) of project:
3. What amount of money is needed for initial implementation of the first six

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