SAMPLE. PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank.

Transcription

1 Grant Application Date Submitted: Proposal Type: If renewal, current grant: Resubmission? 1st or 2nd: TITLE OF PROJECT (s exceeding 81 characters, including spaces and punctuation, will be truncated.) Comm Code: APPLICANT NAME HIGHEST DEGREE(S) POSITION TITLE: ACADEMIC RANK: DIVISION: APPLICANT S CURRENT INSTITUTION MAILING ADDRESS (Street, city, state, postal code, country) DEPARTMENT: ADDRESS: Tel: Fax: PROGRAM ELIGIBILITY INFORMATION: (Responses to selected fields displayed below. For some grant programs this section may be blank.) DATES OF PROPOSED PROJECT (MM/DD/YYYY) From Through SIGNING OFFICIAL FOR PROPOSED BUDGET Tel: Fax: Tel: Fax: EIN ADDRESS DUNS HUMAN SUBJECTS No Yes VERTEBRATE ANIMALS No Yes Human Subjects Assurance No. IRB Status: IRB Date: Animal welfare assurance no. IACUC Status: IACUC Date: ASSURANCE OF THOSE SIGNING THIS APPLICATION: I certify that the statements in this Application that pertain to me and my Institution are true, complete, and accurate to the best of my knowledge, and that I have provided all information required by this Application. I am aware that false, fictitious, or fraudulent statements or claims may result in criminal, civil, or administrative penalties. I agree that I will (and the Signing Official further represents that the institution will) comply with all Grant Policies of the Society, including reporting requirements, to the extent applicable. I understand that a failure to comply with such Policies, or the the terms of the Application, or any additional terms associated with a Grant, may result in the Society suspending or cancelling Grant funding, to be decided by the Society at its sole discretion. The Applicant certifies, and the Signing Official certifies that the Institution has verified, that the Applicant is eligible to work in the United States of America for the period of the award, SIGNATURE OF APPLICANT DATE SIGNATURE OF DEPARTMENT HEAD DATE (In ink. "Per" signature not acceptable) (In ink. "Per" signature not acceptable). SIGNATURE OF SIGNING OFFICIAL (In ink. "Per" signature not acceptable) DATE

2 Applicant: Role Institution Division Dept Role Institution Division Dept Application Contacts Tel: Fax: Tel: Fax: Role Role Institution Institution Division Division Dept Dept Tel: Fax: Tel: Fax: Role Role Institution Division Dept Institution Division Dept Tel: Fax: Tel: Fax: Role Role Institution Institution Division Division Dept Dept Tel: Fax: Tel: Fax:

3 GENERAL AUDIENCE SUMMARY APPLICANT NAME DATE SUBMITTED TITLE OF PROJECT (s exceeding 81 characters, including spaces and punctuation, will be truncated.) This General Audience Summary will become public information; therefore, do not include proprietary/confidential information.

4 Applicant: [Click here and type last name, first name] 1.1 TABLE OF CONTENTS Sections Page Cover Pages (Signature Page, Contact Page, and General Audience Summary) Table of Contents Reply To Previous Review (resubmitted and renewal applications) Copies of prior critiques (resubmitted and renewal applications) I. Department of Social Work Information II. Program Faculty, Field Instructor, and Role Descriptions III. Curriculum Vitae of Field Instructor IV. Curricula Vitae of Key Faculty V. Outline of Program for Trainee Listing of Letters of Support Application Appendix Reports from the field instructor or preceptor and trainee... Application July 2015

5 Applicant: [Click here and type last name, first name] 2.1 REPLY TO PREVIOUS REVIEWS (resubmissions and renewal applications) Application - July 2015

6 Applicant: [Click here and type last name, first name] 3.1 I. DEPARTMENT OF SOCIAL WORK INFORMATION Number of social work FTEs Number of FTEs assigned to adult oncology Number of FTEs assigned to pediatric oncology Average number of cancer patients, both inpatient and outpatient, seen by the social work service annually (including consultations) A. Department Organization and Operations: Describe the social work department and relate it to the organizational structure, including a discussion of how it functions within the institution. If not a department of social work, identify to whom the social workers report within the structure of the facility and describe the relationship. Give a description of the range of social work services and how these services are provided to the patient and family. Describe how the department promotes quality of care in service delivery. Outline what the department is doing to improve services and programs and how students may be involved in this process. B. List the accredited school(s) of social work with which the department and/or institution training site is currently affiliated. Letters of support from currently participating graduate schools must be submitted. Provide a description of all affiliations, both past and present. Include here the history of the association, the number of students placed (annually and overall), and any other relevant educational activities. Describe efforts that promote the integration of field-based activities and the school-based curriculum (Example: a classroom assignment that is carried out in the field such as master s thesis, program plan and/or evaluation, research project, portfolios, etc. Application - July 2015

7 Applicant: [Click here and type last name, first name] 4.1 II. PROGRAM FACULTY A. List faculty (up to six, beginning with the field instructor) in the department of social work or at the training site that will have a significant role in teaching the student; those listed should include the members of the multidisciplinary team. The various roles of the listed individuals must be described in detail in Parts B and C (following). In addition, condensed curricula vitae for the faculty listed below must be included (IV.) and OSW-C certified? B. FIELD INSTRUCTOR - Elaborate the field instructor s role (primary social work supervisor) in the training program. If a director of training exists, describe that role in relation to the role of the field instructor. Include a brief summary of the field instructor s particular strengths, skills, and experience that will enhance her/his ability to teach the clinical practice of psychosocial oncology. Describe the hours of formal supervision to be provided weekly by the field instructor. Include additional information about the availability of the field instructor for supplemental supervision during the hours of placement. Application - July 2015

8 Applicant: [Click here and type last name, first name] 4.2 C. OTHER PROGRAM FACULTY ROLES Explain the roles and relationship, of the other faculty listed above (in part A). Describe how each of these individuals will interact with the student in a teaching role (including time spent with the student) and their special qualifications or specialty area of expertise for the topic that they will be responsible for teaching. Examples might be a social worker that will provide supplemental teaching about family therapy or transplant; a chaplain who specializes in bereavement counseling. It is expected that the student s experiences within the field work placement will include training with faculty at various sites and programs, both internal and external to the institution. (Refer to the Tips in the Policies for specific activities that should be included, especially issues related to cultural competence, multidisciplinary collaboration, domestic violence and suicide screening. Describe opportunities for other members of the multidisciplinary team (those not identified specifically as faculty) to interact with the intern and enhance the learning experience. Describe how this training will be coordinated and the assistance provided to help the student integrate the learning experience as a singular entity. Application - July 2015

9 Applicant: [Click here and type last name, first name] 5.1 III. CURRICULUM VITAE OF FIELD INSTRUCTOR (Limit to two pages; see instructions.) NAME TITLE Education (begin with baccalaureate training) INSTITUTION AND LOCATION FIELD OF STUDY DEGREE AND YEAR CONFERRED Licensure and certification credentials (OSW-C preferred) with dates (As credentials vary from state to state, provide enough detail so that the reviewers understand the nature of the license, for example, identifying that a particular license is for independent clinical practice). Current job title and responsibilities (include academic and teaching responsibilities and dates): Supervisory / field instructor experience (include dates) Indicate years and position that meet minimum of required two years of experience: Experience relevant to oncology Indicate years and position that meet minimum of required two years of oncology practice experience. List chronologically beginning with most recent; include community service/ volunteer activities: Application - July 2015

10 Applicant: [Click here and type last name, first name] 5.2 CURRICULUM VITAE OF FIELD INSTRUCTOR (continued) NAME TITLE Academic/professional honors, awards, consultantships and/or activities. Specify dates and national/local status: Memberships and service to principal national professional organizations (include leadership positions and other levels of participation). List your publications and presentations relevant to oncology practice and teaching; include dates (Provide identifying information on presentations, for example, presentation was a workshop at a national conference, or was to a class of first year graduate students in social work, or part of a community educational program, etc.): Application - July 2015

11 Applicant: [Click here and type last name, first name] 6.1 IV. CURRICULUM VITAE OF KEY FACULTY (limit to two pages; see Instructions) NAME TITLE Education (begin with baccalaureate training) INSTITUTION AND LOCATION FIELD OF STUDY DEGREE AND YEAR CONFERRED Licensure and certification credentials with dates (as credentials vary from state to state, provide enough detail so that the reviewers understand the nature of the license, for example, identifying that a particular license is for independent clinical practice): Current job title and responsibilities (include academic and teaching responsibilities and dates): Cite supervisory and/or field instructor experience; include dates: Other previous training/experience relevant to oncology beginning with most recent; include community service/volunteer activities: Application - July 2015

12 Applicant: [Click here and type last name, first name] 6.2 CURRICULUM VITAE OF FACULTY (continued) NAME TITLE Academic/professional honors, awards, consultantships and/or activities. Specify dates and national/local status: Memberships and service to principal national professional societies: List your publications and presentations relevant to oncology practice and teaching; include dates: (Provide identifying information on presentations, for example, presentation was a workshop at a national conference, or was to a class of first year graduate students in social work, or part of a community educational program, etc.): Application - July 2015

13 Applicant: [Click here and type last name, first name] 7.1 V. OUTLINE OF PROGRAM FOR TRAINEE (items A-F: limit to 10 pages) For renewal applications, this section should address what has been learned from past experience that has been/will be incorporated into the training experience. A. List educational objectives, which should be behavioral and measurable, that you have developed for the proposed trainee. These should demonstrate integration of oncology-specific and general master's level social work training content. Include how evidence-based oncology practice research is integrated into the training, and also how self-awareness and self-care will be included in student s training. Indicate how your educational objectives will complement/enhance the instruction provided by the student s school of social work. B. Describe in detail the program of training planned specifically for the trainee; the program description should detail how the activities will achieve the learning objectives and be clear about what is optional and what is required among available opportunities. Be specific about teaching methods. (For example, modeling and demonstrating are descriptive terms; shadowing is not.) List formal teaching sessions and specific conferences. If the program is restricted to one oncology specialty area, describe how a broad-based acute cancer patient exposure will be provided to the trainee. Provide the average patient caseload for the student with a rationale for the number of patients and the timeline for assignment. Application July 2015

14 Applicant: [Click here and type last name, first name] 7.2 C. INSTITUTIONAL ACTIVITY (Specify pediatric or adult figures as appropriate.) Average daily census: Number of licensed hospital beds: Number of pediatric beds: Number of new adult or pediatric cancer patients diagnosed annually: Number of cancer admissions to the institution annually: If applicable, number of designated cancer beds: Average annual number of outpatient visits of cancer patients (including radiation therapy: Does the institution have organized oncology sections? Is there a functioning multidisciplinary cancer program? Is the multidisciplinary cancer program approved by the American College of Surgeons Commission on Cancer? If applicable, approval from the Joint Commission on Accreditation of Hospitals (JCAHO)? Yes / No Describe the institution/organization and overall training environment in the institution. Provide a description of the patient population. Include a specific or percentage breakdown by race/ethnicity, socioeconomic status and, to the extent possible, sexual orientation. Describe the organized institutional multidisciplinary cancer program. Describe potential training sites available, e.g., inpatient, outpatient, home visits, etc. Include any supplemental sites that could be used to broaden the student s training experience, particularly if the program is based in one oncology specialty area. Describe the link between the social work department and the community, highlighting involvement in programs related to oncology. Application July 2015

15 Applicant: [Click here and type last name, first name] 7.3 D. Training schedule: include a schedule for the training program, beginning with orientation and outlining activities throughout the year. Identify when the assignment of a patient caseload is initiated. If applicable, describe how students will transition from shadowing of the field instructor or other program faculty to more independent clinical work. E. RESOURCES: Describe the facilities and resources that will be made available to the student, e.g., office space, etc. Include a description of how the additional funding available for faculty professional development is proposed to be used [see Policies]. Application July 2015

16 Principal Investigator: [Click here and type last name, first name] 8.1 LISTING OF LETTERS OF SUPPORT List the institutions that are providing letters, and the names and titles of the individuals from whom they have been requested. Application July 2015