APPLICATION FOR OUTCOMES RESEARCH AWARD

(PLEASE PRINT AND READ ENTIRE APPLICATION BEFORE COMPLETING)
(WORD doc file (29K))

MAIL COMPLETED APPLICATION TO:
Committee on Research, c/o Society for Ambulatory Anesthesia
520 N. Northwest Highway, Park Ridge, Illinois 60068-2573

1. Title of Project

2. Name and location (City, State/Country) of Institution(s) where project will be done

3. Funding amount requested (not to exceed $150,000)

4. Principal applicant
Name and Degree
Title/Position/Department
Institution
Mail Address
City/State/Zip/Country
Telephone: Office: Home:
Fax E-mail

5. Official of Institution to be notified in case of award (Name, title, Mail Address)

6. Name and title of Institution official who will administer award funds, if granted

7. CERTIFICATION: The undersigned, individually and collectively, certify that the information contained in this application is complete and correct to the best of our knowledge; that we approve and support the proposal contained herein; and agree that the necessary time, space, personnel and facilities will be provided to support it.

ACCEPTANCE: We also agree that acceptance of the SAMBA Outcomes Research Award, if granted, constitutes an agreement that the Principal applicant and the institution which employs him/her will: 1) adhere to current guidelines for human research; 2) provide an official progress/budget report on the Project to SAMBA by the dates requested and a final report no later than six months following completion of the Project; and 3) acknowledge SAMBA as the/a funding source in all publications resulting from the Project by the following wording: "Supported (or 'Supported in part') by a grant from the Society for Ambulatory Anesthesia."

Principal Applicant Department Head Dean/Institution Head

Typed Name Typed Name Typed Name

8. Date of Application:
Continued on Page 5

All subsequent pages will have header stating:
APPLICATION FOR SAMBA OUTCOMES RESEARCH AWARD
All subsequent pages will have a space at the top of the page for the "Title of Project"

Page 2
Project Summary: (Not to exceed 250 words; double spaced. Provide brief description, aim, relevance to ambulatory anesthesia)

(bottom of page)
Project Dates: The project will be started on (date) and completed on (date).

Page 3:
Name and Degrees of Co-Applicants (include institutional affiliation if different from Principal Applicant):

Standardized Curriculum Vitae:
Complete Appendix A for Principal Applicant and check here .
Complete Appendix B for each Co-Applicant and check here .

Institutional Review Board Approval: Attach all IRB applications and approval letters, as well as copies of the patient informed consent forms (if required) as Appendix C and check here

Other Sources of Funding: All current and pending extra-mural funding, the project titles and any overlap to the proposed project must be disclosed.

List all (including Federal, Institutional, Corporate, etc.) support for this and any related projects for the Principal Applicant and all Co-Applicants. Include which of the applicants has the funding, the funding agency(ies), project dates, funding amount(s), and explanation of how the SAMBA funds will not simply duplicate other funding.

Current Support:
Pending Support:
New Proposals:

Page 4:
Project Budget:

A. Personnel 2004 2005
Name/Title/Function:
Name/Title/Function:
Name/Title/Function:

B. Equipment (itemize)

C. Supplies (itemize by category)

D. Travel

E. Patient Care Costs

F. Other Expenses (itemize)

G. Total per year (not to exceed $75,000 per year)

H. Grand Total (not to exceed $150,000)\
Continued on Page 6

Pages 6-15:
Project Detailed Description: Begin on this page and use continuation pages as necessary, but not to exceed a total of ten double-spaced typewritten pages. Detailed Project Description must include the following in this order: 1) reason for the study/succinct summary of relevant prior knowledge, 2) specific hypothesis to be tested (very important), 3) research methods, including power analysis to support adequacy of sample size, 4) anticipated format of results to prove/disprove hypothesis, 5) statistical analysis to be applied, 6) references.

Appendix A:
Principal Applicant - Standardized Limited Curriculum Vitae

Name: Signature:

Education:
Degree(s) University/Location Scientific Field Year

Post-Graduate Training:
Dates Name of
From-To Institution/Location Department Supervisor

Academic Positions Held:
Dates Name of
From-To Institution/Location Department Supervisor

Publications (List only papers published and those accepted for publication. List only published abstracts in a separate category):

Appendix B
Co-Applicant - Standardized Limited Curriculum Vitae

Name: Signature:

Education:
Degree(s) University/Location Scientific Field Year

Post-Graduate Training:
Dates Name of
From-To Institution/Location Department Supervisor

Academic Positions Held:
Dates Name of
From-To Institution/Location Department Supervisor

Publications (List only papers published and those accepted for publication. List only published abstracts in a separate category):

Appendix C
Attachments of IRB applications, approval letters, and patient informed consents forms.

© SOCIETY FOR AMBULATORY ANESTHESIA
520 N. Northwest Highway Park Ridge, Illinois 60068-2573
Tel: (847) 825-5586 Fax: (847) 825-5658
E-mail: samba@asahq.org