Southeast Region Wocn

SOUTHEAST REGION WOCN Dorothy Doughty Research Grant Information for Applicants

This grant was established in 2005 by the Southeast Region WOCN in honor of Dorothy Doughty, Director of the Emory University WOCNEP and WOCN® past president. The amount of the grant is dependent upon the resources of the SER WOCN, and will be awarded annually.

The selection process will include review of the research proposals by volunteer reviewers with expertise in the nursing research process. Preference will be given to researchers with limited research experience, and to those WOC nurses conducting research as part of a program of study for an advanced nursing degree. The intent of the award is to foster research among members of the SER WOCN. However, if there are no applicants from within the membership of the regional association by the published deadline, the Board of Directors reserves the right to award the grant to a WOCN member from another region with the assistance of the WOCN Center for Clinical Investigation.

Please submit this application Cindy Norris at [email protected]

DEADLINE FOR APPLICATIONS IS JUNE 1, 2014. APPLICATIONS POSTMARKED AFTER JUNE 1 WILL NOT BE CONSIDERED.

Directions for Completion of Application

1. Complete all sections of the application form. Incomplete applications will be returned for completion prior to consideration. Delay in receiving a completed application may result in ineligibility for grant funding. 2. The application form has been designed for electronic completion in Microsoft Word. To complete a check box ( ), simply select the box and click with your mouse. To complete sections requiring a text response, click on the highlighted area ( ) and type. 3. Complete a biographical sketch form for the Principal Investigator and any Co- Investigators. Biographical sketch forms are not needed for data collectors or support team members. 4. Obtain Institutional Review Board (IRB) approval and letter of agreement from all institutions prior to submitting the application. 5. Submit THREE (3) copies of all application materials. Send to the address below. It is recommended that you use a traceable method of mail.

Revised February 2014 SOUTHEAST REGION WOCN Dorothy Doughty Research Grant Application Form

Please complete all portions of the application form.

1. Title of your research project: 2. Your name: 3. Your professional credentials (academic degrees and/or certification): 4. Your home address: 5. Home telephone(including area code): Email address: 6. Name of your current employer: 7. Address of employer: 8. Work telephone (including area code: Email address: 9. Your preferred contact is: Home Work 10. Are you currently a member of the Southeast Region WOCN? yes no Membership number: 11. Is this project being completed as part of an academic program of study? yes no If you answered “yes”, please indicate the degree and expected date of graduation:

12. Do you, or any member of the research team, plan to apply for funding from any other source(s) to complete this project? yes no If yes, please explain: 13. Has this project received any previous funding from any source? yes no If yes, please explain: 14. If this project is approved for funding, will you be accepting the funds directly, or will they be accepted by an employer or academic institution? I will accept directly Funds will be directed to my employer/university If funds will be directed to a third party, please provide the name and address of the appropriate contact person to whom the funds should be sent: Name: Street Address: City, State, Zip code:

Revised February 2014 15. Will this study require access to medical record information? yes no Will this study involve human subjects? yes no If you answered “yes” to either of the questions in #15, please describe how you will protect the confidentiality and the safety of human subjects involved in your study:

16. List all of the individuals, if any, who will be involved in the research project below, and indicate their role in the project. Complete a biographical sketch for the Principal Investigator and each Co-Investigator (see separate page). NOTE: You are NOT required to have a research team to obtain funding. Equal weight will be given to projects completed by individuals.

Name Credentials Role in Research Project Co-Investigator Consultant Data collector Clerical support Co-Investigator Consultant Data collector Clerical support Co-Investigator Consultant Data collector Clerical support Co-Investigator Consultant Data collector Clerical support

17. Please indicate your need for funding for the following items in your project budget.

Budget Line Item Amount Explanation Supplies $

Equipment $

Photocopying $

Services (data collection/entry, $ printing)

Postage $

Consultants $

Computer software $

Other costs $

TOTAL BUDGET $

Revised February 2014 Biographical Sketch Complete for Principal Investigator and each Co-Investigator

NAME: CURRENT POSITION TITLE:

Education Dates of Degree or Institution and Location Credential Attendance Granted

Professional Work Experience Job title: Employer and Location: Dates: Job title: Employer and Location: Dates: Job title: Employer and Location: Dates:

Previous Research Experience Year(s) Your Role in Project

Revised February 2014 Research Proposal

The research proposal may be submitted as a narrative or you may use the form below. If you submit a narrative, it should be no longer than 10 double-spaced pages, using 1 inch margins and a Times New Roman font in size 12 point. The narrative proposal should include all of the headings listed below.

Title of the Study:

Research Question: What is the purpose or aim of this study?

Introduction Why do you feel this study needs to be done?

How does this study relate to your research question?

How do you think your study can be used to improve WOC nursing?

Review of the Literature Include 1 or more paragraphs describing published research studies about this topic and explain the gap in research that your study will try to answer.

Research Methods

What will be the design for your study?

What are the specific variables you will study?

How many subjects will you need for completion of the study? How will you recruit the subjects?

What instruments and procedures will you use to obtain the data?

What statistical tests will you use to analyze the data? If you study is qualitative, how will you analyze the data?

Are there potential problems that you anticipate in doing this kind of a study? How to you plan to avoid those problems when you complete your study?

Revised February 2014 Southeast Region WOCN Dorothy Doughty Research Grant Application Checklist

The following items must be sent to consider your application complete. Please review before sending application.

Required Items

Completed Application Form Biographical Sketch for Principal Investigator Biographical Sketch for each Co-Investigator Research Proposal Letter of approval or exemption for an institutional review board (IRB) or designated committee Letter of approval from the institution in which the study will be conducted (if applicable) Copy of Informed Consent Tool (unless IRB letter indicates that the study is exempt) Copy of Data Collection Tools

Optional Items Letter of support from a research colleague or mentor about the project Letter of agreement from any designated research consultants

Revised February 2014