APPLICATION FORM FOR
PATIENT ORIENTED RESEARCH
PILOT PROJECT AWARD
(please use this as your cover page)

1.    Project Title:  __________________________________________________________

2.    Principal Investigator:  ___________________________________________________
       Address:  ____________________________________________________________
       Telephone Number: ____________________
       Email Address:  _______________________

3.    Biographical Sketch (Use PHS Form 398)

4.    Current and Pending Support for this and other projects (Use PHS 398 format)

5.    Project Proposal:  Title; and Team Aims and Hypotheses; Background and Significance including
       Literature Review; Preliminary Studies or data pertinent to the proposal; Research Design and Methods
       including design rationale, study subjects and sites, study protocol and timetable, study measures and data
       collection, data analysis, power analysis and sample size calculation; External Funding Plans; Explanation
       why this is a pilot protocol (up to three (3) pages).  NB:  Proposals that exceed 3 pages will not be        
        reviewed.

       References (4th page)

6.    Budget:  How the award will be expended (Personnel, Equipment, Supplies), how shortfalls will be
       bridged and what other funds are available.  If external funding is pending at the time of submission, list
       and detail potential award dates and what will happen if projects overlap (one (1) page).

7.    Appendices (up to 2)

        1.  Study protocol or survey instrument, for example.
        2.  No more than two (2) critical references (include copies).
        NB:  Proposals that exceed 2 appendices will not be reviewed.

8.  Attestation: I certify that the statements herein are true, complete and accurate to the best of my knowledge.
     I agree to accept responsibility for the scientific conduct of the project, to comply with FAHC and UVM
     terms and conditions and to provide the required progress reports if a grant is awarded as a result of this
     application. If pending external grants for the same work are funded during the course of a Patient Oriented
     Research Pilot Award, unexpended balance will be returned to the Office of Patient Oriented Research.

    Principal Investigator Signature: ___________________________________________________

(Original and 8 copies of the entire proposal must be submitted to the Office of Patient Oriented Research, Baird 795)