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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