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APPLICATION FOR CWN SUPPORT

for National Research Team and Proposal Development

Intersectoral prevention strategies to address impacts of hydraulic fracturing on Aboriginal communities

Submission deadline: September 9, 2015

|Instructions |

|Please complete this form as your application for CWN support. All fields must be completed and submitted no later than September 9, 2015 11:59 pm |

|(midnight) Eastern Daylight Time. |

|This is not a request for proposals. The intent of the current call for applications is to identify a strong national team with a strong concept that CWN|

|can support in developing a proposal to CIHR and assist in attracting additional partner contributions. The successful team will be notified by CWN no |

|later than September 16, 2015. |

|When complete, the application form should be no longer than 7 pages, including tables and images. Please use a minimum of 11-point font. |

|Text box fields allow tables and images to be inserted. The text boxes on the form pages can be completed by copying from another text document (using |

|the ‘Ctrl’ and ‘v’ keys). Please make liberal use of line spaces and capitals to make the text easier to read. You will not be penalized for using white |

|space. |

|You may contact CWN for assistance: |

|If you require technical help with this form, contact Janice Levangie at jlevangie@cwn-rce.ca or 519-888-4567 ext. 39354. |

|If you have questions about the desired content of the application, please contact Katrina Hitchman at khitchman@cwn-rce.ca or 519-888-4567 ext. 37943. |

| |

|Nominated principal applicant information |

|Provide the following details for the individual acting as the team lead and key point of contact for this application. |

|Last name: |      |First name: |      |

|Title: |      |

|Department: |      |

|Institution: |      |

|Telephone: |      |

|City: |

|Proposal concept |

|Provide a high level overview of the approach your team would take to respond to the CIHR funding opportunity within the framework provided by CWN. That |

|is, how would your team assess the suitability of current regulations, policies, and systems to prevent health impacts of hydraulic fracturing activities|

|in Aboriginal communities? How would you design a project comprising studies and comparative assessments to provide concrete value by directly informing |

|policy and practice decisions with a demonstrable expectation of improved prevention of negative health outcomes? |

|(Maximum 750 words) |

|      |

| |

|Project team |

|Describe the members of the proposed project team (including extended project partnerships) and indicate each team member’s anticipated role in the |

|project. |

|Please distinguish between the independent researchers for whom you would seek CIHR funding and knowledge users, other researchers, and partners who |

|would provide input but would be supported through “leveraged” or in-kind funding from other sources. To indicate overall capacity, you may list |

|separately those likely to contribute to the projects in an advisory capacity. |

|Please indicate clearly which principal applicant will be the designated Traditional Knowledge Keeper/Elder for the team. |

|Briefly list each team member’s area of expertise and outline their research excellence, qualifications and experience for their proposed role in the |

|project. |

|If additional rows are needed please contact Janice Levangie at jlevangie@cwn-rce.ca. |

|(Maximum 1.5 pages) |

|*For more details on CIHR’s team composition eligibility requirements, refer to the CIHR Team Grant: Environments and Health: Intersectoral Prevention |

|Research funding opportunity website. |

|Independent researchers (supported by CIHR funding) |

|Name |Academic institution |Project role |Area of expertise/qualifications |

| | |*Nominated principal applicant | |

|      |      |      |      |

| | |*Principal applicant | |

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|Knowledge users, other researchers, and partners (supported by other leveraged or in-kind funding) |

|Name |Organization |Project role |Area of expertise |

|      |      |* Knowledge user and principal |      |

| | |applicant | |

| | |      | |

|      |      |*Knowledge user and |      |

| | |co-applicant | |

| | |      | |

|      |      |*Knowledge user and |      |

| | |co-applicant | |

| | |      | |

|      |      |      |      |

|      |      |      |      |

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|      |      |      |      |

|Others taking part in the project in an advisory capacity |

|Name |Organization |Project role |Area of expertise |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

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|4. Team composition and structure |

|Describe how the proposed team’s research excellence, established competence, and experience are well suited to address the issues adequately and achieve|

|improved prevention of negative health outcomes. In particular, highlight: |

|How the team’s interdisciplinary, multi-institutional, intersectoral, and cross-regional makeup is well suited to address the issues. |

|The team’s experience and familiarity with relevant practices, regulations, policies, and systems, and how the issues to be examined relate to these |

|practices, regulations, policies, and systems. |

|(Maximum 750 words) |

|      |

|5. Existing relationships with Aboriginal communities |

|Describe the team’s existing relationships with Aboriginal communities located across Canada for whom impacts of hydraulic fracturing on health are an |

|important issue. Describe any demonstrated interest in your proposed project from Aboriginal organizations and groups, especially Aboriginal communities,|

|including proposed partners. |

|(Maximum 400 words) |

|      |

|6. Additional expertise required |

|As appropriate, CWN may provide assistance to the successful team in connecting with additional expertise required by the research topic. If assistance |

|is required, briefly indicate what type of expertise the team would benefit from adding, and what role this additional expertise would play in the |

|proposed project. |

|(Maximum 250 words) |

|      |

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