Request for Penn Resiliency Program
Please complete this form on your computer word-processing program and return it to us via email at prpresearch@ gmail.com. Thank you!
INVESTIGATOR INFORMATION AND EXPERIENCE:
Name: ______
Please provide your contact information Position/Title: Department: Address: Phone: Fax: Email:
Please answer the following questions about your training and previous research experience NOTE: Please also include a copy of your resume or c.v.
1. Do you have an advanced degree in psychology or another research-related field? ___ Yes ___ No
If yes, please answer questions 1a through 1d below. If no, please skip to question 2.
1a. Field of study: ______
1b. Degree (e.g., M.A., Ph.D.)______
1c. Year of degree: ______
1d. Name of Institution: ______
1e. Location of Institution: ______
2. Do you have previous experience conducting research on psychological and/or educational interventions? ___ Yes ___ No
If yes, please briefly describe this research.
3. Do you have advanced training in Cognitive-Behavioral therapy for depression or anxiety disorders?? ____ Yes ____ No
If yes, where did you complete this training?
______Briefly describe this training.
PRP Manual Request Application July 5, 2007 CO-INVESTIGATOR INFORMATION AND EXPERIENCE: Please have ALL Co-Investigators complete this form
Name: ______
Co-Investigator contact information Position/Title: Department: Address: Phone: Fax: Email:
Please answer the following questions about your training and previous research experience NOTE: Please also include a copy of your resume or c.v.
1. Do you have an advanced degree in psychology or another research-related field? ___ Yes ___ No
If yes, please answer questions 1a through 1d below. If no, please skip to question 2.
1a. Field of study: ______
1b. Degree (e.g., M.A., Ph.D.)______
1c. Year of degree: ______
1d. Name of Institution: ______
1e. Location of Institution: ______
2. Do you have previous experience conducting research on psychological and/or educational interventions? ___ Yes ___ No
If yes, please briefly describe this research.
3. Do you have advanced training in Cognitive-Behavioral therapy for depression or anxiety disorders?? ____ Yes ____ No
If yes, where did you complete this training?
______
Briefly describe the training.
PRP Manual Request Application July 5, 2007 PROJECT PLAN Please prepare a brief proposal describing the project you are planning to conduct. Include the following information.
A. Research Aim. What are the major goals of this project? What hypotheses do you plan to evaluate?
B. Research Design. Describe the methods you plan to use. Include information about the following: a. Sample (e.g., age/grade range, general demographic characteristics, selection criteria, exclusion criteria), recruitment plan, and anticipated sample size b. Location of study (e.g., clinic, school, other community organization) c. Study conditions (e.g., comparison/control groups, other intervention conditions) and method by which participants will be assigned to condition (e.g., random assignment) d. Evaluation plan (e.g., types of outcome data that will be collected, length of follow- up) and brief description of plan for statistical analyses e. Anticipated start date and Duration of study
C. Plan to use the Penn Resiliency Program. How do you plan to administer the intervention in your study? Include information about the following. a. Number of groups, number of group leaders, and approximate number of participants per group b. Qualifications of group leaders c. Plan for training and supervising group leaders d. Will the PRP intervention be used in its entirety, or do you plan to use components of the intervention? e. Do you plan to adapt, modify, or translate the curriculum?
D. Funding source. Is the project funded by a grant from the government or another non-profit institution?
E. Collaboration. Does this study involve a collaboration between yourself and one (or more) of the researchers who have developed the Penn Resiliency Program? If so, please indicate who you will be working with and what you anticipate his/her role to be on the project.
PRP Manual Request Application July 5, 2007 Please have all investigators sign below.
I, the aforementioned investigator ______, agree that:
The PRP materials are copyrighted by the University of Pennsylvania.
If my application to use the program materials is approved, I will have permission to photocopy and use the materials in the described study only.
By signing below I agree not to use the materials outside of that research project and I agree not to market, sell, edit, reprint, or distribute the materials to others.
______Signature Date
______Signature (Co-Investigator) Date
______Signature (Co-Investigator) Date
PRP Manual Request Application July 5, 2007