Appendix AP roject Submission Form WORD

							                                                                                        Appendix A




                                     CLINICAL INNOVATION FUND
                                       Project Submission Form



PROJECT TITLE:



PROJECT LEAD (must be an AFP participating physician)

Name:

Email address:

Faculty Appointment:
(i.e. Asst. Professor)

Institution:

Department:


CO-INVESTIGATORS:

          Name                                     Institution

1.

2.

3.


FUNDING:

Duration of Project:                       One year ____                Two year ____

Amount of Funding Requested:
                                           Year 1: $ 0                  Year 2: $ 0
(Maximum amount per project - $50,000.)

Is this project supported financially by
                                           Yes ____                     No ____
another organization or institution?

If “yes”, please specify the source and amount received or requested.

        Source                                                     Amount

1.                                                                 $0

2.                                                                 $0

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                                                                                              Appendix A


FUNDING MANAGEMENT:

Please provide the name and contact information for the transfer payment agency that will manage the
project funds.

Name of Institution:

Address:

Contact person:

Email address:

NOTE: If there is no appropriate transfer agency, the funding will be transferred to NOSM Research Unit
      for administration. Examples of appropriate transfer agency include: hospital, clinic, LEG


RESOURCE IMPLICATIONS

Are there resource implications, such
as space and staff for other
                                           Yes ____                     No ____
institutions, i.e. hospital, clinic,
NOSM?

If “yes”, a letter of support from the institution must be attached.



PROJECT SUMMARY

Please provide a summary of the project in non-technical language following the outline provided in the
Project Summary Framework document (Appendix B).




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