JPB Grant Letter of Intent Form

J. Patrick Barnes Grants For Nursing Research and Evidence-Based Practice Projects

Letter of Intent For All Applicants

Please complete this form and submit by the deadline for Letters of Intent. We will inform you as to whether your study is approved for a full proposal.

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Date of Letter of Intent Submission: *

Name of Proposed Study: *

SHORT Name of Proposed Study (50 characters maximum): *

PROJECT TEAM LEADER

PL - First Name: *

PL - Last Name: *

PL - Credentials: *

PL - Email Address: *

PL - Phone Number: *

IF THERE ARE ADD'L PEOPLE ON YOUR TEAM - YOU MAY LIST UP TO 5 TOTAL

FIRST Team Member

1 - First Name:

1 - Last Name:

1 - Email Address:

1 - Phone Number:

1 - Role in Study:

SECOND Team Member

2 - First Name:

2 - Last Name:

2 - Email Address:

2 - Phone Number:

2 - Role in Study:

Do you have more than two team members? *

THIRD Team Member

3 - First Name:

3 - Last Name:

3 - Email Address:

3 - Phone Number:

3 - Role in Study:

FOURTH Team Member

4 - First Name:

4 - Last Name:

4 - Email Address:

4 - Phone Number:

4 - Role in Study:

FIFTH Team Member

5 - First Name:

5 - Last Name:

5 - Email Address:

5 - Phone Number:

5 - Role in Study:

INSTITUTION INFORMATION

Institution Name: *

Street: *

City: *

State: *

Zip Code: *

Will the application be for: *

STUDY PROPOSAL INFORMATION

(To determine the number of words you are using, type in a Word document first and use word count. Then copy/paste into the form below.)

Background: (Maximum 250 words) *

Purpose of Study/Description of how this study/project will benefit cancer or auto-immune disease patients and/or family members of patients with an auto-immune disease or cancer, in keeping with DAISY Foundation's stated goal: (Maximum 200 words) *

General outline of study: Methods/Sample/Setting/Procedure: (Maximum 250 words) *

Do you have a mentor for your study? *

If Applicant has a Mentor, please enter the information below:

Mentor's First Name: *

Mentor's Last Name: *

Mentor's Credentials: *

Mentor's Email: *

Mentor's Phone Number: *

Mentor's Current Position: *

Would you like the DAISY Foundation to contact you about providing a Mentor? *

Do you plan to apply to DAISY for subsequent funding to help you disseminate your findings? *

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