Jefferson Public Citizens Program Application

Jefferson Public Citizens Program Application 2009-10 1 st DEADLINE: 12:00 noon on November 17, 2009. Jefferson Public Citizens (JPC) project abstracts (max 500 words) are due to the Institutional Review Board for pre-review. 2 nd DEADLINE: 12:00 noon on December 1, 2009. JPC Final Application (see checklist below). Late applications not accepted. SUBMIT TWO (2) COMPLETE, COLLATED COPIES TO: Office of University Community Partnerships 1 st floor, Booker House, 1709 University Ave Paper Clips or Binder Clips only. No staples please! Jefferson Public Citizens (JPC) Application Checklist: Completed JPC Application Form including Application Forms for JPC Team Members Recommendation Letter from Faculty Advisor Project Endorsement Letter from Community Partner on organization s letterhead. Email Copies will be accepted in some cases. Unofficial Transcripts for each Team Member Copy of the Institutional Review Board s Pre-Award Determination Notice (required for all JPC project proposals) Preliminary Work Plan University Community Partnership Agreement *if community partner is abroad and/or unable to sign agreement, they should specifically state their acceptance of the terms of the agreement in their Endorsement Letter. How did you hear about the Jefferson Public Citizens Program? UVa Website Facebook Twitter Email Friend Faculty Member Flyer Information Session Advertisement Other Page 1 of 10

JPC Application Form PART ONE Primary Student Contact for JPC Proposal: Name: Email: Phone: Year: Major: JPC Team Project Title: List of JPC Team Members: Each Team Member must also complete and attach: (1) a Team Member application form and (2) an unofficial transcript. Name 1. 2. 3. 4. 5. U.Va. email id If you are applying for other grants to support this project, please check which ones: Center for Global Health Grant Double Hoo Award Miller Center Grant Institute for Practical Ethics Internship College of Arts & Sciences Small Research Grant Other (please list) Harrison Award Echols Research Grant Kenan Award Raven Fellowship Community-Based Grant Yes, this project includes an application for a JPC Graduate Student Mentor. Graduate Student Name: U.Va. email id: Page 2 of 10

Yes, this project would continue work from a previous JPC Project. Please provide: Previous Project Title: Previous Team Members: Previous Faculty Advisor: JPC Projects and the Institutional Review Board: If your proposed JPC project will involve working with human or animal subjects, your work may be subject to approval by the Institutional Review Board (IRB). The IRB ensures the university s compliance with federally mandated research guidelines. All JPC project applicants must send a project abstract (500 word maximum) to irbsbs@virginia.edu before 2 weeks before the JPC Application deadline. Please use JPC Application in your subject line. You will receive a reply indicating whether your proposed project requires IRB approval and, if so, what steps you will need to take to obtain that approval. You must submit a copy of the IRB s response with your JPC application. For more information on the IRB, we strongly encourage you to watch a brief presentation available online at: http://www.virginia.edu/vpr/irb/learningshots/undergraduate_research/player.html This JPC Project will involve working with human or animal subjects. Copy of IRB s Pre-Award Determination Notice is enclosed. Faculty Advisor Endorsement Faculty Advisor, please initial the following statements and sign below. I agree to advise the work of [insert JPC project title]. I approve the proposed JPC Project budget. If the project involves human and/or animal subjects, I will advise my students to comply with the policies of the University s Institutional Review Boards. I understand that I also may be required to undergo online IRB training. If the project involves international travel, I will advise my students to register with the International Studies Office, attend a pre-departure orientation, and comply with any other ISO requirements. I will review the team s final project and submit a one-page final evaluation to the Office of University Community Partnership when requested. Signature of JPC Faculty Advisor For International JPC Projects: This JPC Project proposes international travel to (list country) Page 3 of 10

Proposed JPC Project Budget: PART TWO BUDGET ITEM ITEMIZED COSTS SUBTOTAL I. Travel Costs A. Transportation For example: Plane tickets Bus tickets Train tickets Taxi fares Trip cancellation insurance Public transportation Car rental Gas Car insurance Visa fees Travel Costs B. Living Expenses Room rental Food Travel Costs C. Medical Expenses Immunizations Medications & Prescriptions (e.g. malaria) Medical Evacuation insurance II. Stipends for Team Members (up to $3,000 per team member) III. Project Materials and Supplies For example: Printing Copying Internet access International cell phones Software Translators Transcribers Training or workshop fees Small thank you gifts for hosts Hospitality for community events Physical equipment Building materials TOTAL AMOUNT REQUESTED Page 4 of 10

PART THREE The JPC Project proposal narrative: Please discuss following in the project narrative (maximum 700 words): 1. Research question your JPC project will address and why is it important 2. Background or previous work done on this problem a. If your project would continue the work of a previous JPC project, please explain what is new and different about your project and how it will build on earlier JPC efforts. 3. Methodology, i.e. how the team project will approach the problem 4. Anticipated outcomes of the project and how the team will accomplish them 5. Follow up evaluation of project including benefits for the community partner Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut feugiat elementum velit sit amet lacinia. Donec lorem massa, rhoncus id euismod vel, faucibus eu urna. Fusce hendrerit nunc leo, id iaculis ligula. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Phasellus scelerisque elementum erat, non lobortis dui egestas sit amet. In rutrum, nisi nec mattis hendrerit, turpis turpis rhoncus libero, non facilisis magna arcu eu metus. Mauris non mi magna, non mollis dui. Nunc gravida sodales viverra. Integer porta ultricies augue a auctor. Praesent malesuada justo vel dui consectetur vitae sodales ante auctor. Sed eget sem sed mi interdum cursus. Sed dapibus diam ac eros gravida non lobortis mauris hendrerit. In ultricies euismod elit, ac ultricies erat congue ullamcorper. Aliquam erat volutpat. Integer bibendum volutpat gravida. In porta, metus et tempor facilisis, dolor lectus interdum risus, vel placerat turpis nisl vel libero. Vestibulum in semper dui. Ut pulvinar orci id nunc consectetur auctor. Sed porta enim non felis varius sagittis. Duis ullamcorper vestibulum eros, id tincidunt felis consectetur at. Proin dolor elit, adipiscing eget blandit ut, iaculis nec dui. Suspendisse ultricies, neque vel elementum facilisis, nulla erat facilisis diam, sit amet egestas nisi erat id magna. Phasellus fringilla odio eget dui tempor porta. Pellentesque leo ante, malesuada lacinia pharetra nec, tempor nec mi. Duis adipiscing leo id neque scelerisque euismod. Nam nec nisl ut lorem mattis volutpat. Nulla dapibus facilisis orci, in malesuada lectus ultricies in. Aenean vitae magna sed erat cursus feugiat nec eu sem. Nullam ac rutrum justo. Donec vel dictum tortor. Vivamus facilisis, orci nec tristique pretium, ligula dui fringilla lacus, lacinia porttitor risus turpis nec felis. Nunc gravida arcu id ligula tincidunt vestibulum. Pellentesque porttitor mauris non justo accumsan mollis luctus purus ultricies. Etiam a elit ligula, a adipiscing dolor. Nam dictum congue nunc, fermentum mollis metus ornare eu. Morbi iaculis blandit leo tempor posuere. Mauris sodales dignissim ligula, vel mollis ipsum ultrices non. Donec vel urna et quam laoreet egestas nec id nibh. Vivamus vulputate lacus quis eros luctus pellentesque. Praesent ac neque metus. Integer pulvinar lectus vulputate tortor vehicula feugiat at ut ipsum. Morbi bibendum mauris quis metus semper tincidunt. Integer luctus lobortis lectus eget elementum. Maecenas bibendum feugiat justo, nec pretium odio varius at. Donec mattis odio sit amet libero tincidunt facilisis. Vestibulum pellentesque cursus varius. Proin a neque ante, sit amet fringilla magna. Mauris scelerisque iaculis turpis, non consequat elit tristique id. Nullam ultrices arcu eu mauris fringilla eget ultricies erat malesuada. Sed nisi Page 5 of 10

velit, pulvinar eget fringilla at, venenatis in ante. Pellentesque ac odio a purus accumsan molestie. Sed faucibus erat a odio faucibus consectetur. Curabitur quis velit est, eu gravida leo. Vestibulum in libero sed sem placerat porttitor ut eu tellus. Pellentesque venenatis, velit eu auctor mattis, nisi mauris lacinia libero, sed laoreet turpis neque ac nunc. Nulla ac nisi dui. Vivamus aliquet nibh sapien. Integer at sollicitudin diam. Donec aliquam dui at turpis pulvinar bibendum. Nulla sed tortor eget purus placerat ultrices id in metus. Aliquam ac odio at sem pretium tincidunt et a ante. Nulla purus odio, pharetra sit amet porta ut, rutrum sit amet neque. Donec id velit nec velit fermentum porttitor. Sed sit amet ornare mauris. Duis urna purus, bibendum sed fringilla ut, malesuada in arcu. Nam id lorem id turpis tincidunt laoreet sit amet interdum velit. Donec sed vestibulum lorem. Duis at augue velit, non adipiscing arcu. Fusce id pharetra ligula. Donec quis nibh dui. Curabitur non nisl sed lorem ullamcorper rhoncus nec et nisl. Quisque id lorem eget tortor iaculis scelerisque. Phasellus sed nulla est. Fusce ullamcorper turpis nec mi elementum rhoncus. Maecenas pretium eros a dolor porttitor et dictum nisl tincidunt. Duis condimentum odio a odio tempor tincidunt. Nunc diam lacus, luctus gravida tincidunt nec, fringilla sed odio. Praesent convallis enim at enim porttitor vel aliquam nibh porta. Aliquam erat volutpat. Ut sit amet odio sapien. Mauris eu sem non eros viverra imperdiet vel non lectus. Aliquam nisl urna, commodo sed faucibus et, accumsan at purus. Class aptent taciti sociosqu ad litora torquent per conubia nostra, per inceptos himenaeos. Morbi vulputate, mauris ultrices faucibus sagittis, mi sem vehicula mi, quis iaculis odio erat eget nisi. Proin in risus. Page 6 of 10

PART FOUR JPC Team Member Application Form Submit one for each team member followed by an unofficial transcript Name: U.Va. Email: Phone: Year: Major: Academic Advisor: Academic Advisor s department: Academic Advisor s e-mail address: Describe your role/contributions (non-monetary) to this JPC Project: [100 words]lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla velit nibh, tristique in feugiat at, adipiscing a enim. Phasellus cursus viverra sapien. Quisque aliquam ullamcorper suscipit. Nunc vitae neque dui. Maecenas dignissim quam et felis mattis sed aliquet arcu vulputate. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Proin erat elit, pretium vitae ornare at, pretium sit amet velit. Duis consectetur ornare leo, a fringilla massa venenatis at. Fusce neque elit, dictum sed consequat sed, elementum eget sem. In egestas, nunc mattis imperdiet vulputate, turpis quam gravida mi, et condimentum metus justo eget sapien. Suspendisse venenatis, mauris et volutpat luctus. Discuss your previous experience working in teams (does not have to be athletic teams): [100 words]lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla velit nibh, tristique in feugiat at, adipiscing a enim. Phasellus cursus viverra sapien. Quisque aliquam ullamcorper suscipit. Nunc vitae neque dui. Maecenas dignissim quam et felis mattis sed aliquet arcu vulputate. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Proin erat elit, pretium vitae ornare at, pretium sit amet velit. Duis consectetur ornare leo, a fringilla massa venenatis at. Fusce neque elit, dictum sed consequat sed, elementum eget sem. In egestas, nunc mattis imperdiet vulputate, turpis quam gravida mi, et condimentum metus justo eget sapien. Suspendisse venenatis, mauris et volutpat luctus. Page 7 of 10

Describe your prior and current experience with community engagement and service. What did you accomplish and what was the impact on the community? [200 words]lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla libero lorem, consequat in posuere quis, luctus a sapien. Quisque egestas ligula id sapien volutpat rhoncus in in lacus. Integer fermentum pulvinar tortor, sed lobortis nisi pretium vel. Sed nibh ligula, egestas vitae ullamcorper sed, bibendum accumsan orci. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Quisque magna justo, convallis sed lacinia et, sodales sit amet metus. Morbi condimentum ornare lacinia. Aenean turpis lectus, placerat eu scelerisque dapibus, semper at lectus. Maecenas porta volutpat tincidunt. Maecenas venenatis tellus et ligula aliquam aliquet. Sed pulvinar vehicula magna sed aliquet. Pellentesque vestibulum nulla in libero congue vitae vestibulum turpis sagittis. Curabitur ornare, libero sed euismod rhoncus, tellus mi interdum felis, at tincidunt ipsum nunc condimentum justo. Nam eu magna at orci tincidunt consectetur sed eget arcu. Mauris eleifend gravida mi, a semper libero malesuada in. Praesent vel felis a metus rutrum convallis nec non mauris. Vivamus adipiscing, nisl feugiat vehicula laoreet, nisi lacus adipiscing tellus, eu semper nisl diam ac velit. Suspendisse sapien quam, laoreet a semper quis, ultrices ut nulla. Donec non elit dolor, eu sollicitudin lacus. Nullam vulputate euismod nisi in pharetra. Maecenas elementum est in. List your previous and current coursework relevant to this JPC Project and describe the specific skills and experience you bring to the team and the project. [200 words]lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla libero lorem, consequat in posuere quis, luctus a sapien. Quisque egestas ligula id sapien volutpat rhoncus in in lacus. Integer fermentum pulvinar tortor, sed lobortis nisi pretium vel. Sed nibh ligula, egestas vitae ullamcorper sed, bibendum accumsan orci. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Quisque magna justo, convallis sed lacinia et, sodales sit amet metus. Morbi condimentum ornare lacinia. Aenean turpis lectus, placerat eu scelerisque dapibus, semper at lectus. Maecenas porta volutpat tincidunt. Maecenas venenatis tellus et ligula aliquam aliquet. Sed pulvinar vehicula magna sed aliquet. Pellentesque vestibulum nulla in libero congue vitae vestibulum turpis sagittis. Curabitur ornare, libero sed euismod rhoncus, tellus mi interdum felis, at tincidunt ipsum nunc condimentum justo. Nam eu magna at orci tincidunt consectetur sed eget arcu. Mauris eleifend gravida mi, a semper libero malesuada in. Praesent vel felis a metus rutrum convallis nec non mauris. Vivamus adipiscing, nisl feugiat vehicula laoreet, nisi lacus adipiscing tellus, eu semper nisl diam ac velit. Suspendisse sapien quam, laoreet a semper quis, ultrices ut nulla. Donec non elit dolor, eu sollicitudin lacus. Nullam vulputate euismod nisi in pharetra. Maecenas elementum est in. Page 8 of 10

List your participation in any non-credit workshops, lectures, events, or training relevant to this JPC Project and the impact it has made on your understanding of community engagement: [200 words]lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla libero lorem, consequat in posuere quis, luctus a sapien. Quisque egestas ligula id sapien volutpat rhoncus in in lacus. Integer fermentum pulvinar tortor, sed lobortis nisi pretium vel. Sed nibh ligula, egestas vitae ullamcorper sed, bibendum accumsan orci. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Quisque magna justo, convallis sed lacinia et, sodales sit amet metus. Morbi condimentum ornare lacinia. Aenean turpis lectus, placerat eu scelerisque dapibus, semper at lectus. Maecenas porta volutpat tincidunt. Maecenas venenatis tellus et ligula aliquam aliquet. Sed pulvinar vehicula magna sed aliquet. Pellentesque vestibulum nulla in libero congue vitae vestibulum turpis sagittis. Curabitur ornare, libero sed euismod rhoncus, tellus mi interdum felis, at tincidunt ipsum nunc condimentum justo. Nam eu magna at orci tincidunt consectetur sed eget arcu. Mauris eleifend gravida mi, a semper libero malesuada in. Praesent vel felis a metus rutrum convallis nec non mauris. Vivamus adipiscing, nisl feugiat vehicula laoreet, nisi lacus adipiscing tellus, eu semper nisl diam ac velit. Suspendisse sapien quam, laoreet a semper quis, ultrices ut nulla. Donec non elit dolor, eu sollicitudin lacus. Nullam vulputate euismod nisi in pharetra. Maecenas elementum est in. Why do you want to be part of the Jefferson Public Citizens program? [150 words]lorem ipsum dolor sit amet, consectetur adipiscing elit. Duis malesuada blandit tortor, condimentum porttitor mauris faucibus molestie. Nulla eu leo vel nisl tincidunt rutrum. Nunc imperdiet porta ullamcorper. Curabitur eget diam urna. Nunc non arcu et lectus viverra vehicula sed id velit. Vestibulum tempus, quam et molestie gravida, est risus porttitor mauris, in posuere dolor mauris in velit. Donec mattis mollis est vitae tempor. Pellentesque auctor justo in nulla consectetur pretium. Mauris suscipit consequat est imperdiet luctus. Curabitur erat orci, rhoncus a hendrerit faucibus, ornare nec dui. Nunc sit amet leo quam, at dictum arcu. Pellentesque scelerisque dolor non dolor facilisis nec mattis sapien venenatis. Morbi ullamcorper feugiat condimentum. Donec pulvinar arcu in massa bibendum vel euismod sem mollis. Nunc bibendum consectetur risus, non aliquam erat egestas ullamcorper. Vestibulum placerat purus elit. Nullam luctus, diam eget rutrum ultrices, elit purus facilisis ante, id sollicitudin urna dolor quis orci. Vestibulum ante. You may use the space below to provide additional information about other experiences you have had that would be relevant to this JPC project. [100 words]lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla velit nibh, tristique in feugiat at, adipiscing a enim. Phasellus cursus viverra sapien. Quisque aliquam ullamcorper suscipit. Nunc vitae neque dui. Maecenas dignissim quam et felis mattis sed aliquet arcu vulputate. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Proin erat elit, pretium vitae ornare at, pretium sit amet velit. Duis consectetur ornare leo, a fringilla massa venenatis at. Fusce neque elit, dictum sed consequat sed, elementum eget sem. In egestas, nunc mattis imperdiet vulputate, turpis quam gravida mi, et condimentum metus justo eget sapien. Suspendisse venenatis, mauris et volutpat luctus. Unofficial Transcript Attached Page 9 of 10

Team Member Endorsement Please initial each of the following statements and sign below. I promise to adhere to all JPC Award procedures, including the submission of my mid-term report, final project, expenditure report, and presentation. If the project involves human and/or animal subjects, I will seek advice from my faculty advisor, and I will comply with the policies of the University s Institutional Review Boards. If the proposed JPC project involves international travel, I understand that: I may not travel to any location with a U.S. State Department Travel Warning and, if such a warning is issued while I am abroad, I must leave the country immediately in the safest manner possible. (http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html). Prior to my departure, I will register with the International Studies Office, attend a pre-departure orientation, and comply with any other ISO requirements. www.virginia.edu/iso. I am responsible for obtaining a visa and/or work or other permit required for my intended destination. I am responsible for getting appropriate inoculations and overseas health/emergency coverage. If I am an international student, I will consult with an international student advisor about my visa status. Signature of JPC Team Member Page 10 of 10