Research Support Application Form

Applications will be received on a quarterly basis for consideration by the Alzheimer Society Research Committee. Please submit application for review by 1600 hours on the last Thursday of April, September and December. Please consult the Alzheimer Society Research Policy on this website before completing this application.

Fields indicated by an (*) are required

 

Before you begin...
It is strongly recommended that you frequently SAVE your information as you work through the form.

PRINCIPAL INVESTIGATOR'S INFORMATION

* First Name :

* Last Name :

* Phone Number/Ext :

* Email :

* Have you previously applied for Alzheimer Society Research Support? Yes No

Date : January February March April May June July August September October November December / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032

Title :

Were you successful in obtaining Alzheimer Society Approval? Yes No

Did you disseminate the results? Yes No

Please describe dissemination activities in space below (e.g., presentations, publications).

Co Investigator 1 : Add another

 

Research Support Request

* Title :

Type of Research Support Request (you may check more than one box):
Non - Monetary Support
Monetary Support
Student Research Project
Health Care Organizations

Please check (√) boxes that apply:
Conduct a pilot study
Conduct a research study
Program evaluation
Team Development; Community Partnetships
Proposal Development
Recruitment of Subjects ( Attach consent form for participants )
Letter Support
Advertisement of project/study
Others ( Please describe )

Please describe briefly.

Do you intend for this proposed project to lead to a larger proposal for funding from another source? Yes No

Please describe briefly.

*Does this project involve human or animal subjects? No Yes ( including interviews, questionnaires, observations of behaviour, use of non-public records that contain identifying information, administration of drugs, blood samples, tissue samples, tests or other procedures )

*Has the application received the approval by credible experts? Yes No

Please attach any ethics certificates received by an external Research Ethics Board (REB) or a letter providing names and the organizational affiliation of the credible ethics experts.


If this Research Funding Request is for a small, applied clinical research project, attach a letter of support/review by your internal Professional Advisory Committee.

 

*1. Purpose of Research Support Request

Please provide a lay description of the proposed project/study

Please describe the purpose and background rationale for the project, as well as the hypothesis or research question for the project/study

Please provide a statement of the relevance/significance of the proposed project/study

*2. Methodology of Research Support Request

Please describe all procedures in which research participants will be involved (e.g. paper and pencil tasks, interviews, surveys, questionnaires, time requirements, etc.)

Please attach a copy of all questionnaires, interview guides and test instruments.

*3. Protection of the anonymity of participants

Please outline measures that will be used to protect anonymity of participants both during the conduct of the research and the dissemination of results

4. How does this research project support the mission, research principles and priorities of the Alzheimer Society?

5. How does this research project fit into the current broader research environment?

6. What will be the estimated burden on Alzheimer Society staff? Please be specific in terms of your expectations for involvement of Alzheimer Society staff.

7. Budget and Budget Justification (If you are requesting non-monetary support, please skip section 7, and move directly to section 8. For all research applications requesting financial support, a budget must be included.

Personnel :
State the roles of research personnel and explain why you require the level (in terms of qualifications and salary) you are requesting
$

Travel and Subsistence :
Please indicate the purpose of the trip(s), the people who will be traveling, and their destination
$

Professional Services :
(e.g., transcription, translation, data analysis, knowledge translation specialist, project consultant)
$

Supplies and Other Expenses :
Itemize the expendables (for eg. quantity, description and per unit cost).
$

Other Expenses :
Please itemize and explain each item.
$

Are you seeking funding for this project from other sources? Yes No

Please elaborate.

*8. Timeline

Date when the project can be started, if funded : January February March April May June July August September October November December / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032

Duration of the proposed project :

Please elaborate on major tasks and completion dates :

9. Research products and plans for dissemination

Provide a clear indication of the expected outcome of the proposed research (e.g., publication in a journal, preliminary stage of a large project, how the project will lead to future funded research applications, etc). Outline plans for the dissemination of results. (approx 250 words)

 

ADDITIONAL RELATED INFORMATION

* Is this part of a larger study? Yes No

Please elaborate.

 

UPLOAD CV

Upload CV(s) of Principal Investigator and Co-Investigators (if any) (PDF or MSWord(doc) Only)