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? (versus 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 350 characters) *

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