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Janus Research Grant Application Form 2011 Deadline for submission: March 1, 2011 PLEASE SELECT ONE OF THE FOLLOWING:  NOVICE RESEARCH RESEARCHER (up to $5,000)  NOVICE/INTERMEDIATE/SENIOR RESEARCHER (up to $10,000) Name: CFPC Membership #: (Principal Investigator) Address: City: Prov: Postal Code: Email: Name/s of co-investigator/s: 1.________________________________________ 3.______________________________________ 2.________________________________________ 4.______________________________________ EACH SECTION MUST BE COMPLETED. INFORMATION MAY BE ATTACHED OR SUBMITTED ELECTRONICALLY. INCOMPLETE SUBMISSIONS WILL NOT BE REVIEWED. PLEASE REFER TO GUIDELINES FOR DETAILS PROJECT TITLE: Total duration of project: (month/year to month/year) Section 1. Summary. A summary of your project is required, suitable for public information, max 250 words. Section 2. Study Design. A full protocol for the research project is required. Section 3. Ethical Approval. Required If your study involves humans or animals as subjects. Please select one of the following:  Attached  Pending – application attached  Pending – will be submitted on receipt  Not applicable Section 4. Clinical trial registry. If this is a clinical trial, please provide the registration number & registry.  Required: Registration number:__________ Registry: ___________________________  Pending – application attached  Not applicable Section 5. Personnel. List if applicable. a. Job title/description: Hourly rate: Number of hours: b. Job title/description: Hourly rate: Number of hours: c. d. Job title/description: Hourly rate: Number of hours: Job title/description: Hourly rate: Number of hours: Continued on next page Janus Research 2011 Section 6. Travel costs List if applicable t travel costs in detail. Does not cover the costs to present the data at a conference. Section 7. Essential equipment required for project. List if applicable. Does not cover the costs of computers or laptops. Section 8. Supplies & services. List if applicable. Section 9. Project team member information. Attach a CV (max 5 pages) relevant to the proposed project for each project team member. A common CV may be submitted. A longer CV will not be reviewed beyond the first 5 pages. Section 10. Total funds requested at this time: Personnel Services: $ _______ Travel: $ _______ Equipment: $ _______ Supplies/Services: $ _______ TOTAL: $ _______ Section 11. Overall project funding. If total project funding exceeds the total requested from this Janus Research Grant application, please provide details of how the difference will be achieved. Members who have already received this award cannot apply for the same award 2 years in a row. Applications must be received by March 1, 2011 Submit online at www.cfpc.ca/awards or send this form by email, fax, or mail to Email: kziten@cfpc.ca Fax: (905) 629-0893 or 1-888-843-2372 The College of Family Physicians of Canada Honours & Awards Committee 2630 Skymark Ave, Mississauga, ON L4W 5A4