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Application Details

Date of Application:

Amount Requested (up to $10,000. Please do not include $ sign):

Study Title:

SHORT Name of Study Title (50 characters maximum):

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

From (choose date from calendar):

To (choose date from calendar):

How did you learn about the Health Equity Grants Program?

Principal Investigator Information:

DAISY Foundation Grants are only available if your Principal Investigator is a RN. Please confirm this is true below.

First Name:

Last Name:

Credentials:

Title:

Email:

Phone:

We support studies conducted by nurses who are both inexperienced and experienced in research and EBP. Please tell us your level of experience. (This will have no bearing on the evaluation of your application. It is for our information only.)

Additional Team Members/Investigators

If there are additional people on your team please add them below- you may list up to 5 total

Do you have additional Team Members/Investigators to add?

How many team members/Investigators do you wish to add?

Additional Team Member/Investigator #1

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #2

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #3

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #4

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Additional Team Member/Investigator #5

First Name:

Last Name:

Credentials:

Title:

Role of Team Member:

Email:

Phone:

Payment Information:

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

Institution Name:

Attention:

Street:

Department/mail stop/PO box, etc.:

City:

Country:

State:

Provinces:

State/Province:

Postal Code:

Institution Information

Institution Name:

Street:

City

Country

State:

Provinces

State/Province

Postal Code

Institutional Official

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

Institutional Official Contact Information:

First Name:

Last Name:

Credentials:

Title:

Email:

Phone:

Mentor Information

We strongly encourage our applicants to have mentors for their work, especially if you are not a highly experienced researcher. Hopefully a mentor will be available in your own institution or a nearby college/school of nursing.

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

Mentor: If you have a project mentor, please enter their information below:

First Name:

Last Name:

Credentials:

Mentor's Insitution:

Title/Position in institution:

Email:

Phone:

IRB Information:

Are human subjects involved?

Has IRB approval been granted?

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?

Is your project IRB-exempt? If so, please upload your IRB exemption letter below.

Please complete the following proposal. Please number your references throughout. (For example, “Cholesterol is comprised of two values(3)”. Then, please use APA format and detail your corresponding references on an attachment. (For example, Smith and Jones, 2012.)

Social Determinants of Health

Which SDOH will be addressed by this work? (hold Ctrl key for multiple selection)

Abstract

Abstract (Maximum 250 words):

Significance/Background

Significance/Background (Maximum 750 words):

NOTE ABOVE:
Describe the background of your proposal, including:

Review of the literature: A critical evaluation of the existing body of knowledge about the problem.
The significance of this study by relating it to existing knowledge. Why this work is important?
A description of the target population and SDOH(s) your work addresses and why (can have more than one).
References that are uploaded as an attachment (upload explained below).

Hypothesis

Hypothesis (Max 100 words)

NOTE ABOVE: Your Hypothesis should be specific.

Methods

Methods (Maximum 1,000 words):

NOTE ABOVE:

Detail the methods you will use for the research/project.
- Identify your sample (characteristics, sample size, provide power analysis as appropriate to justify your sample size). Explain the difficulty or ease you believe you will have recruiting your sample and why you feel this way. If there will be challenges, how will you overcome them?
- Specify the protocols and instruments you will use. If you are using a particular instrument, provide a copy as an attachment. As appropriate, provide information on the psychometric properties of the instrument you are proposing to use. Please be sure you have already obtained permission to use your tools so that this study is ready to implement once your IRB has approved it and we have agreed to fund it.

Describe outcome variables in detail.
Describe your proposed data analysis plan in detail.

Explain how you will maintain confidentiality.

Community Needs

Alignment with Your Organization’s Assessment of Community Needs (300 words)

NOTE ABOVE: How does your work fit the needs of your community as described in your organization’s or your community’s assessment of the community’s needs?

Link to Community Needs Assessment report for your organization: E.g. www.communityneedsassessment.org

Permissions

Are you using a copyrighted tool or instrument that requires permission from the author, publisher, or organization, etc. who created it?

If you are using a tool that requires permission, please confirm that you have permission now to use the tools you propose

From whom do you have permission? Please list tools and permissions granted. Be sure to upload your tool or instrument at the end of this form (directions below) and written permission to use it.

Clinical Nurse Engagement

How will clinical nurses 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. Your plan should not exceed 12 months.

Your Timeline:

Create a spreadsheet identical to the one above to present your project’s timeline. Include additional steps from the EBP process model you identified previously as guiding this project work. 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).

Your Budget:

Create a spreadsheet identical to the one above to present your project’s budget. Please upload your budget below.

Documentation

DOCUMENTATION – Upload the documents listed below.

Budget

Timeline

Tools or instruments you are using

Interview formats, discussion guides, etc.

Consent Forms- if consent forms are required for IRB approval, they must be submitted with this application.

References (detail the sources of your assumptions and literature review)

Applicant's resume or CV. Please highlight funded and unfunded studies and EBP projects.

Permission to use the tools or instruments

If you have a Mentor, the Mentor's biosketch or abbreviated CV. This should include the Mentor's accomplishments/experience/academic training as they relate to this project.

Proof of IRB approval or letter of exemption if you have it. If you do not have input from your IRB, you may apply and provide the approval prior to DAISY's funding of the grant.

Letter of Agreement (see below)

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.

Letter of Agreement:

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. These reports will be submitted through The DAISY Foundation website.
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 submit my study to the Virginia Henderson Library of Sigma Theta Tau International within 30 days of filing my final report with The DAISY Foundation.
That I will credit funding from The DAISY Foundation upon publication/presentation of this research, using the authorized DAISY Foundation logo to be provided by The Foundation.
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___________________________________________________

Acknowledgemnt

By checking this box and submitting the online form, you agree to The DAISY Foundation collecting and storing your personal contact information. We may contact you if we have questions about your submission or to discuss next steps. To learn more, please read our Privacy Policy.

I Agree

Please note: You may need to allow a few minutes for the form to process. If the form becomes stuck on "please wait" or you are not re-directed to another page after you hit submit, please email Christina Johnson at ChristinaJohnson@DAISYFoundation.org to confirm we have received your submission. Thank you!

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