Better Knowledge for Safer Care

SMALL RESEARCH GRANTS FOR PATIENT SAFETY

FOR OFFICIAL USE ONLY Date received: ______________________ ID: _________________________

Part I: Summary of Administrative Information

1. Name of the principal investigator and institutional affiliation:
Last name: First name:

Title: Occupation:
Date of Birth(dd/mm/yyyy) Sex: M /F
Contact details Full postal address of the Principal Investigator for official communication. For
telephone and fax numbers, please provide country and area codes.
(Office and institutional address) (Home)

Telephone (W): Telephone (H):

Fax:
E-mail-1 (mandatory): E-mail-2: (optional)

2. Co-investigators (There are no limits to the number of co-investigators. Please add more space
or provide additional pages if necessary)
2.1 Last name: First name:

Title: Occupation:
Date of Birth: Sex: M /F Phone:
Email:
2.2 Last name: First name:

Title: Occupation:
Date of Birth: Sex: M /F Phone:
Email:
2.3 Last name: First name:

Title: Occupation:
Date of Birth: Sex: M /F Phone:
Email:

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 Better Knowledge for Safer Care

Project Summary
Project title

Principal investigator(s) and contact

details

Co investigators and affiliated

institutions

Project Manager and contact details

Administering institution, country

Collaborating institutions

Project location, city and country

Ethical review body

Main funding agency

Other funding agency (if any)

Project Budget

Project Duration

Estimate start date

Estimate finish date

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 Better Knowledge for Safer Care

PART II: RESEARCH STUDY PROPOSAL

1. Title of the project:

2. Project Summary (This should be about 350 word and self contained as an abstract)

3. Background and Rationale: (This includes literature review of previous studies on the subject;
and rationale of the study by stating the problem and its public health importance. Please include
references as needed)

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4. Study goal, objectives and main research questions:

4.1 Goal and objectives: (state the goal and objectives you need to achieve)

4.2 Research questions: (state the specific research questions that will enabling the achievement of
each objective that will finally lead to achievement of the goal)

1.

2.

3.

4.

5.

(more, if any)

4.3 Secondary objectives/ questions: (These are subsidiary objectives that could be studied during
the course of the project but are not the main objectives of the study, they are optional)

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5. Methods

5.1 Setting: (Describe the area or setting where the study will be conducted)

5.2 Study design: (Describe the type of study design eg cross-sectional, case-control study, etc..)

5.3 Study subjects: (State clearly eligibility and exclusion criteria of the study subjects)

5.4 Sample size and sampling techniques: (Describe the input criteria for sample size estimation
and the sampling technique that will be used in order to obtain a representative sample for your
target population.)

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5.5 Data Collection methods, instruments used, measurements

(Describe the instruments/tools to be used for data collection (questionnaire,observation recording

form, etc..), and studied variables included in these instruments, as well as the methods used to test
for the validity and reliability of the instrument)

5.5.1 Study definitions (e.g. case definition)

5.5.2 Main variables and measures (including dependent and independent variables and
covariates)

5.5.3 Instruments/tools (to be used for data collection and studied variables included in these
instruments. If applicable, please attach a copy of the questionnaire or tools to be used and ensure
that they are appropriately referenced.)

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5.5.4 Techiques/ methods (used to test the applicability, validity and reliability of the instrument.
Please indicate appropriate references if using already validated tools)

5.5.6 Data management and analysis plan: (Describe the analysis plan and statistical packages
to be used)

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6. Expected direct products (outputs)

7. Implications of study results on patient safety practice and/or interventions

(Expected results and potential contribution of the project to patient safety)

8. Dissemination of results and publications plan

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9. Ethical Considerations:

9.1 Ethical considerations (Illustrate that your research proposal is acceptbly safe, respect the
rights of participants, data treated with confidentiality etc. Discuss any other issues that are likely to
raise ethical concerns and how you will address them.)

9.2 Informed consent form (If applicable, discuss the issues that are likely to raise ethical
concerns and describe how the investigator(s) plan to obtain informed consent from the research
participants. If needed, please attach extra documents)

9.3 Institutional ethical clearance

o Do you have an ethical review board in your institution? Yes No

o Institutional ethical clearance has been obtained for the study: Yes No

(In case there is no institutional ethical review board, the clearance of a national ethical review
body or clearance of the Ministry of Health could be accepted. )

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10. Bibliographic references (List relevance references including journal articles)

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 Better Knowledge for Safer Care

Part III- A: Project Management and Organisation

11. Project plan and duration (provide an outline of the project plan. Indicate when the project
will commence and specify the time that each phase of the project is likely to take.

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 Better Knowledge for Safer Care

12. Timelines:(Please indicate the activities to be conducted and mark the corresponding month on the Gantt chart. The project should be
limited to 18 months at the most)

Key milestones MONTH (from project commencement)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Progress report
(required)

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12. Timelines:(Please indicate the activities to be conducted and mark the corresponding month on the Gantt chart. The project should be
limited to 18 months at the most)

Key milestones MONTH (from project commencement)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Final report
(required)

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 Better Knowledge for Safer Care

13. Budget* (The budget section should contain a detailed breakdown of the funds requested for,
along with a justification for each item)
Budget Other
Budget Breakdown Unit cost ($US) Sources
($US)** ($US)

Total

GRAND TOTAL

*Not exceeding $US 25,000. Please consult the Conditions of Grants for
admissible expenses.
**unit cost of each item should be accurately given to allow proper budget evaluation.

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13.1 Budget justification (Discuss and justify the costs stated in the budget table. State the value of
the project costs in local currency and how they compared with other similar projects conducted in
the same areas).

14. Risks and assumptions (Discuss the difficulties that the investigators anticipate in the course
of completing the projects within the time frame and budget and explain possible solutions to deal
with these difficulties).

15. Annexes: (Please list data collection instruments or any other related documents that you wish
to attach here and attach them to the application)

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 Part III- B: Project Management and Organisation

16. Project team and project management (List project team members both academic and
administrative staff and describe their role and responsibilityies. Use the format: Name, Position,
affiliated organisation, role in the project )

17. Networks/ collaborations (if applicable) (describe the collaboration established or

implemented)

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18. Other funding agency

Is this project part of the study funded by another funding agency: Yes No
(If yes, please specify the agency and available funds)

19. Other information (Provide other relevant information. If needed, please attach relevant
documents)

19.1 Collaboration with other scientists or research institutions

19.2 Links to other projects etc. (Indicate if this study is linked to or part of other projects/studies. If
so, please explain.)

19.3 Other research activities of the principal investigator -should list all current research projects
that he/she is involved in, the source of funding of those projects, the duration of those projects and
the percentage of time spent on each.

19.4 Financing and Insurance (Illustrate that the institution has the ability and capacity to
administer the grant).

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