CIHR-IHSPR Rising Star Award: Application Form

Instruction to help you fill out this form

Review CIHR funding programs to ensure that your request for funding cannot be funded by an existing CIHR funding program. If you require help to determine this information please contact the specific contact person from the Institute which you are seeking support.
Obtain a CIHR Personal Identification Number (PIN) if you do not already have one by going to the following web address and following the instructions.
Fill out the following application form and save it. (Not applicable- you will not be able to save it).
Print a copy and sign it to be sent by mail to the Institute(s) you are applying to for funding.
Send an electronic copy of this application form to the same Institute(s) you are applying to for funding (you can scan your printed copy and send an electronic application).

1. Applicant Information

CIHR PIN
Name of Applicant
Affiliation
Institution paid
Address
Telephone Number
Email

2. Request for Funding Information

Project Title
Are you applying as an
Individual, or as an
Organization
If you are requesting funds from other CIHR Institutes please indicate them. (Not applicable)
- Institute of Aboriginal Peoples' Health
- Institute of Aging
- Institute of Cancer Research
- Institute of Circulatory and Respiratory Health
- Institute of Gender and Health
- Institute of Genetics
- Institute of Health Services and Policy Research
- Institute of Human Development, Child and Youth Health
- Institute of Infection and Immunity
- Institute of Musculoskeletal Health and Arthritis
- Institute of Neurosciences, Mental Health and Addiction
- Institute of Nutrition, Metabolism and Diabetes
- Institute of Population and Public Health
If you are requesting funds from other sources than CIHR please list them. (Not applicable)
Total amount requested. (Write $1,000)
Start date of funding request: month/day/year. (Not applicable)
Duration of funding request (in months). (Not applicable)

Using the following model, please submit, as an attachment to this application, a budget table that includes names of all funding sources, amounts and timelines requested for this activity. (Not applicable)

Source of funds	$ requested 2008-2009	$ requested 2009-2010	$ requested 2010-2011	Total


Total

Provide a justification for the amount and duration of the funding request. (Not applicable)

3. Activity Description

Please provide a brief biographical sketch including information about general research/thesis interests, previous training and research experience, current training and career aspirations (maximum 250 words).
For Research Article: Please provide the full citation for your published article (title, authors, name of journal, volume, page numbers, and year). Please attach an electronic copy of your article to the completed form.

For KT Initiative: Please provide the full title of your KT initiative and include names of all other authors/participants, if applicable. Please attach an electronic copy of your 1000 word description (maximum) of your KT initiative (including objectives, activities, outcomes, and impact) and a summary of your KT experience and impressions (e.g., what worked well, what did not work well, and why).
Relevance and Potential Impact of the Article/KT initiative: Please write a statement describing the relevance and potential impact of your paper and/or KT initiative within the field of health services and policy research (maximum 250 words).
Please attach an electronic or hard copy of the article or 1000 word summary of the KT Initiative and a letter of support from your research supervisor.

4. Signatures

Name of Applicant
Signature of Applicant
Date

Please mail or email your application by February 3, 2012 to: