Form 1 Request for Support of Research Project

Family Medicine

Amended September 19, 2012, December 5, 2012, September 2013

FORM 1: REQUEST FOR SUPPORT OF RESEARCH PROJECT Please note that the process from submission to approval may take up to four months. In addition, funding requests are only considered in February and October each year.

INSTRUCTIONS: One Centre only If requesting support from ONE centre only, please send this form directly to the individual centre (see contact information below).

More than One Centre If requesting support from more than one academic centre, please send this form to Ms. Maureen Kennedy, Department Research Committee Coordinator, at the Centre for Studies in Family Medicine ( address listed below).

NAME PHONE/FAX EMAIL ADDRESS Dr. Anna 519.433.8424 [email protected] Victoria FMC Pawelec- x. 60 Chesley Avenue Bryzychczy F. 519.433.5796 London, Ontario N5Z 2C1

Dr. Sonja 519.672.9660 [email protected] St. Joseph’s FMC Reichert F. 519.672-7727 346 Platt’s Lane London, ON N6G 1J1

Dr. Sonny 519.472.9672 [email protected] Byron FMC Cejic F. 519.657-1766 1228 Commissioners Rd. W. London, ON N6K 1C7

Dr. Ted 519.264.2800 [email protected] Southwest Middlesex HC Osmun F. 519.264-2742 RR#5, 22262 Mill Road Mt. Brydges, ON N0L 1W0

Ms. Maureen 519.661.2111 Maureen.Kennedy@sch Centre for Studies in Family Kennedy x 22059 ulich.uwo.ca Medicine, Western University F. 519.858-5029 WCPHFM, 1151 Richmond St. 2nd floor, Rm 2138 London, ON N6A 3K7

Ms. Joanne 519.661.2111 [email protected] Western University Gibb x.86611 o.ca Dept. of Family Medicine, F. 519.661-3878 Western Centre for Public Health and Family Medicine, First floor London, ON N6A 5C1

Centre for Studies in Family Medicine Western University Western Centre for Public Health and Family Medicine 1151 Richmond St, Second floor (Rm. 2138) London, ON, Canada N6A 3K7 t. 519.661.2111 x 22059 f. 519.858.5029 http://www.uwo.ca/fammed/csfm/ Form 1 Request for Support of Research Project Department Research Committee Amended September 2013 Date: Request # (Office use Only)

Applicant Name: Full Mailing Address: Phone:

Email:

1. Title of Research Project

2. Do you have Ethics approval?  Yes – continue to question 3; attach copy of the one-page ethics approval  Submitted, not yet approved; continue to question 3; forward copy of 1 page ethics approval once received  Not yet submitted – do not complete/submit this Request for Support

3. Principal Investigator(s)(include Institutional Affiliations and email address)

4. Primary Contact Person (s) (e.g. Project Coordinator) Name: Address: Phone: Fax: E-mail:

5. Please check which centre(s) will be involved:

 Victoria FMC  St. Joseph’s FMC  Byron FMC  Southwest Middlesex HC

 Centre for Studies in Family Medicine

 Department of Family Medicine (e.g. administrative data)

 Other: ______

6. Is this a request to survey the Western Family Medicine Residents?  Yes  No

7. Have members of the Department of Family Medicine been involved in preparation of the research question, intervention, questionnaire etc.?  Yes  No

If yes, please describe involvement (and provide names of those who have been or who will be involved).

8. Will family physicians/providers be involved in providing data (i.e. data from physicians)?

 Yes  No If yes, how many family physicians in each centre will be recruited?______

Will family physicians be asked to facilitate the collection of patient data?

 Yes  No If yes, how many patients in each centre will be recruited?______

2 Form 1 Request for Support of Research Project Department Research Committee Amended September 2013

Overall, how much time will the study require of participating physicians?

______

9. Project duration:

Estimated start date of project: (mm/yyyy) ______Estimated complete date: (mm/yyyy) ______

10. Stage of project:

 Pilot project  Continuation of previous work  New research

11. Project duration:

Estimated start date of project: (mm/yyyy) ______Estimated complete date: (mm/yyyy) ______

12. Stage of project:

 Pilot project  Continuation of previous work  New research

13. Brief Description of Project, including background, research question/hypothesis, research objectives, literature review, reference list. (please attach, maximum 2 pages )

14. Brief Description of Methodology, including recruitment, data collection and analysis (please attach, maximum 1 page, plus all relevant measures)

15. List any resources to be provided to centre(s), such as financial support, equipment, photocopying/mailing support, research assistant:

16. List any resources required, including involvement/participation required of centre(s)’ staff members (Please list tasks by staff member and time estimates):

17. How will the results of the research project be helpful to family physicians, patients, the Department of Family Medicine, or the research community in general? (Please describe.)

18. Will the results be shared with:  the physicians/providers or patients involved in the research  other family physicians and health care providers  research colleagues

3 Form 1 Request for Support of Research Project Department Research Committee Amended September 2013

19. Please describe plans for using or sharing results of the research following the project (presentations, workshops, media release, newsletters, publications etc.), including any specific plans to share the results with participating centre(s).

19. REQUESTS FOR FUNDING: The Department of Family Medicine has funding available from the Research Trust Fund for its faculty, residents and Master of Clinical Sciences graduate students although it is expected that other sources for funding will be sought prior to applying to the Research Trust Fund. If you wish to request funding for the project please indicate your affiliation and check below:

 Faculty  Resident  Masters of Clinical Science student

Please specify items and related amounts (i.e. photocopying, supplies, postage) along with total budget amount requested (attach maximum one page budget) See Document 2 for additional information on funding.

Print Full Name of Applicant Signature of Applicant

Print Full Name of Supervisor (if applicable) Signature of Supervisor (if applicable)

Date Submitted:

Application Instructions: email, fax or mail Form 1 to :

Department Research Committee c/o Centre for Studies in Family Medicine Western Centre for Public Health and Family Medicine 1151 Richmond St. Second floor (Rm. 2138) London, ON N6A 3K7 Attention: Ms. Maureen Kennedy

Phone: 509.661.2111 x 22059 Fax: 519.858.5029 email: [email protected]

Upon notification of funding approval, submit all ORIGINAL RECEIPTS to: Ms. Jody Moon Department of Family Medicine Western Centre for Public Health and Family Medicine 1151 Richmond St, (First floor) London, ON N6A 3K7