Nursing Research Council Research Project Application



Ann & Robert H Lurie Children’s Hospital of Chicago

Chicago, Illinois

NURSING RESEARCH COUNCIL

Application for Approval of Research Study

Date Submitted: _______________________________________________________

Name of Primary Investigator: _______________________________________________________

Mailing Address: _______________________________________________________

_______________________________________________________

_______________________________________________________

Phone (W)_____________________ (H)_____________________

Highest Degree Earned/Institution: ________________________________________________________

Present Academic or Institutional Affiliation: _________________________________________________

Status (faculty, student, staff, etc.): ________________________________________________________

If a student, name of Faculty Advisor: ______________________________________________________

Faculty Advisor’s Business Phone: ________________________________________________________

Have you conducted/participated as an investigator or data collector in a research study before? Yes No

If yes, specify title of study and your role: ____________________________________________________

Name of other investigator(s) for this project: _____________________________________________

_____________________________________________________________________________

Current project title: _______________________________________________________________

Projected Dates for Data Collection: _________________________________________________________

Has the proposal gone through a prior review process (Institutional Review Board, University/College Review board, etc.)? If so, please describe:

__________________________________________________________________________________________________________________________________________________________

Was the proposal approved? Yes No

Estimated Cost of the Project $______________________________

Amount and Source of Funds (available, and/or to be requested):__________________________________

Do you have an internal contact person or sponsor?_____________________________________________

If yes, please state name and phone number: __________________________________________

Specify personnel, facilities, equipment required and/or arrangements made: ________________________

______________________________________________________________________________________

Have you contacted and received approval in writing from the appropriate Lurie Children’s Division and/or Department Heads? Yes No

If yes, name and department _______________________________________________________

______________________________________________________________________________________

*Please provide these letters of support with your application.*

If this proposal is approved, I agree to:

1. Comply with all policies and regulations of the Medical Center.

2. Accept the decisions of the Nursing Research Council and the Institutional Review Board within its jurisdiction.

3. Submit a copy of any publication resulting from research to the Nursing Research Council.

4. Present findings at a research meeting or forum sponsored by the Nursing Research Council if asked.

Signature: _____________________________________________________________

(Primary Investigator)

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