Better Knowledge for Safer Care

SMALL
FOR OFFICIAL USE ONLY

RESEARCH GRANTS FOR PATIENT SAFETY

Date received: ______________________ ID: _________________________

Part I: Summary of Administrative Information 1. Name of the principal investigator and institutional affiliation: Last name: Title: Date of Birth(dd/mm/yyyy) First name: Occupation: Sex: M /F

Contact details Full postal address of the Principal Investigator for official communication. For telephone and fax numbers, please provide country and area codes. (Office and institutional address) (Home)

Telephone (W): Fax: E-mail-1 (mandatory):

Telephone (H): E-mail-2: (optional)

2. Co-investigators (There are no limits to the number of co-investigators. Please add more space or provide additional pages if necessary) 2.1 Last name: Title: Date of Birth: 2.2 Last name: Title: Date of Birth: 2.3 Last name: Title: Date of Birth: Sex: M /F Sex: M /F Sex: M /F First name: Occupation: Phone: Email: First name: Occupation: Phone: Email: First name: Occupation: Phone: Email: 1

WHO World Alliance for Patient Safety-Small Research Grants: Application form

Better Knowledge for Safer Care Project Summary Project title Principal investigator(s) and contact details Co investigators and affiliated institutions

Project Manager and contact details Administering institution, country Collaborating institutions

Project location, city and country Ethical review body Main funding agency Other funding agency (if any) Project Budget Project Duration Estimate start date Estimate finish date

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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Better Knowledge for Safer Care PART II: RESEARCH STUDY PROPOSAL 1. Title of the project: 2. Project Summary (This should be about 350 word and self contained as an abstract)

3. Background and Rationale: (This includes literature review of previous studies on the subject; and rationale of the study by stating the problem and its public health importance. Please include references as needed)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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4. Study goal, objectives and main research questions: 4.1 Goal and objectives: (state the goal and objectives you need to achieve)

4.2 Research questions: (state the specific research questions that will enabling the achievement of each objective that will finally lead to achievement of the goal) 1. 2. 3. 4. 5.

(more, if any)

4.3 Secondary objectives/ questions: (These are subsidiary objectives that could be studied during the course of the project but are not the main objectives of the study, they are optional)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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5. Methods 5.1 Setting: (Describe the area or setting where the study will be conducted)

5.2 Study design: (Describe the type of study design eg cross-sectional, case-control study, etc..)

5.3 Study subjects: (State clearly eligibility and exclusion criteria of the study subjects)

5.4 Sample size and sampling techniques: (Describe the input criteria for sample size estimation and the sampling technique that will be used in order to obtain a representative sample for your target population.)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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5.5 Data Collection methods, instruments used, measurements (Describe the instruments/tools to be used for data collection (questionnaire,observation recording form, etc..), and studied variables included in these instruments, as well as the methods used to test for the validity and reliability of the instrument) 5.5.1 Study definitions (e.g. case definition)

5.5.2 Main variables and measures (including dependent and independent variables and covariates)

5.5.3 Instruments/tools (to be used for data collection and studied variables included in these instruments. If applicable, please attach a copy of the questionnaire or tools to be used and ensure that they are appropriately referenced.)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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5.5.4 Techiques/ methods (used to test the applicability, validity and reliability of the instrument. Please indicate appropriate references if using already validated tools)

5.5.6 Data management and analysis plan: (Describe the analysis plan and statistical packages to be used)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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6. Expected direct products (outputs)

7. Implications of study results on patient safety practice and/or interventions (Expected results and potential contribution of the project to patient safety)

8. Dissemination of results and publications plan

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9. Ethical Considerations: 9.1 Ethical considerations (Illustrate that your research proposal is acceptbly safe, respect the rights of participants, data treated with confidentiality etc. Discuss any other issues that are likely to raise ethical concerns and how you will address them.)

9.2 Informed consent form (If applicable, discuss the issues that are likely to raise ethical concerns and describe how the investigator(s) plan to obtain informed consent from the research participants. If needed, please attach extra documents)

9.3 Institutional ethical clearance
o o

Do you have an ethical review board in your institution?

Yes

No No

Institutional ethical clearance has been obtained for the study: Yes

(In case there is no institutional ethical review board, the clearance of a national ethical review body or clearance of the Ministry of Health could be accepted. )

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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10. Bibliographic references (List relevance references including journal articles)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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Better Knowledge for Safer Care

Part III- A: Project Management and Organisation 11. Project plan and duration (provide an outline of the project plan. Indicate when the project will commence and specify the time that each phase of the project is likely to take.

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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Better Knowledge for Safer Care

12. Timelines:(Please indicate the activities to be conducted and mark the corresponding month on the Gantt chart. The project should be limited to 18 months at the most) Key milestones 1 2 3 4 5 6 MONTH (from project commencement) 7 8 9 10 11 12 13 14 15 16 17 18

Progress report (required)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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12. Timelines:(Please indicate the activities to be conducted and mark the corresponding month on the Gantt chart. The project should be limited to 18 months at the most) Key milestones 1 2 3 4 5 6 MONTH (from project commencement) 7 8 9 10 11 12 13 14 15 16 17 18

Final report (required)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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Better Knowledge for Safer Care 13. Budget* (The budget section should contain a detailed breakdown of the funds requested for, along with a justification for each item) Budget Other Budget Breakdown Unit cost ($US) Sources ($US)** ($US)

Total GRAND TOTAL *Not exceeding $US 25,000. Please consult the Conditions of Grants for admissible expenses. **unit cost of each item should be accurately given to allow proper budget evaluation.

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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WHO World Alliance for Patient Safety-Small Research Grants: Application form

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13.1 Budget justification (Discuss and justify the costs stated in the budget table. State the value of the project costs in local currency and how they compared with other similar projects conducted in the same areas).

14. Risks and assumptions (Discuss the difficulties that the investigators anticipate in the course of completing the projects within the time frame and budget and explain possible solutions to deal with these difficulties).

15. Annexes: (Please list data collection instruments or any other related documents that you wish to attach here and attach them to the application)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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Part III- B: Project Management and Organisation 16. Project team and project management (List project team members both academic and administrative staff and describe their role and responsibilityies. Use the format: Name, Position, affiliated organisation, role in the project )

17. Networks/ collaborations (if applicable) (describe the collaboration established or implemented)

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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18. Other funding agency Is this project part of the study funded by another funding agency: Yes (If yes, please specify the agency and available funds) No

19. Other information (Provide other relevant information. If needed, please attach relevant documents) 19.1 Collaboration with other scientists or research institutions

19.2 Links to other projects etc. (Indicate if this study is linked to or part of other projects/studies. If so, please explain.)

19.3 Other research activities of the principal investigator -should list all current research projects that he/she is involved in, the source of funding of those projects, the duration of those projects and the percentage of time spent on each.

19.4 Financing and Insurance (Illustrate that the institution has the ability and capacity to administer the grant).

WHO World Alliance for Patient Safety-Small Research Grants: Application form

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