Team Grant Registration Form

Principal Investigator (PI) First Name *

Principal Investigator (PI) Last Name *

VCH/PHC Job Title *

E-mail address *

Phone (work) *

VCH/PHC program/dept *

University faculty appointment (if applicable)

Are you a full-time/part-time VCH staff? *

Yes

No

Is this a permanent position? (vs. temporary, contract, etc) *

Yes

No

Are you a VCH/PHC physician? *

Yes

No

If so, is VCH your primary place of work (vs. private practice or another health organization) *

Yes

No

N/A - Not a physician

Who is your program/dept manager who will be signing the application *

Please provide name as well as position

In which VCH/PHC HSDA(s) do you work? *

What is the name of the site/building that best describes where your primary work site? *

Co-Principal Investigator (Co-PI) name, department, & academic institution *

Briefly describe the research expertise the Co-PI brings to the team, including their current area of research *

Co-investigators (names, programs/departments, and organizations (if not VCH)) *

What is your proposed research question or hypothesis? (Maximum 600 characters) *

Keyword 1 (used to facilitate peer-review process) *

Keyword 2

Keyword 3

Do you plan to have a patient or family partner on your team? *

Yes

Maybe

No

Are you interested in support to develop a patient-oriented approach to your research project? *

Yes

Maybe

No

As the proposed PI, have you read all of the eligibility criteria in the competition guidelines and determined that you are eligible to apply and your project fits the competition? *

Yes

No

Have you ever held research operating funds from an external funding agency? *

Yes

No

If any of the above information changes after registration submission, please send the revised registration form to education.award@vch.ca.

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Team Grant Registration Form