ACKNOWLEDGEMENT OF RECEIPT FORM

FPHTC COLLABORATIVE PROJECT APPLICATION

Spring/Summer 2013

FULLY SIGNED PROPOSALS MUST BE RECEIVED no later than 5:00 p.m.

on December 14, 2012

by the Florida Public Health Training Center

send to clphp@health.usf.edu

ELECTRONIC PDF SUBMISSION: Please save this acknowledgement form, the entire, fully signed application, and allowable supporting documents as a PDF file, and e-mail it to clphp@health.usf.edu by the deadline.

Do not include a cover letter or outside cover.

     Project Leader

      Department Name

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * To be completed by the FPHTC office:

Date of receipt_____________________________________ Application #_____________________

FPHTC Collaborative Project Application

University of South Florida – College of Public Health

Florida Public Health Training Center (FPHTC)Collaborative Project Application

Funded by the U.S. Department of Health and Human ServicesHealth Resources and Services Administration (HRSA)

Form #2 (Page 1 of 3) Awards Guideline

Title of Proposal:      

Name of USF COPH Faculty:      

Department Name:      

Faculty E-mail Address:      

Faculty Campus mailing address:      

Faculty Campus phone number:      

Faculty Rank/Title:      

Name of USF COPH Student:      

Department Name:      

Student E-mail Address:      

Student Campus mailing address:      

Student Campus phone number:      

Student Home mailing address:      

Student Home phone number:      

Name of DOH Representative:      

Department Name:      

Office E-mail Address:      

Office mailing address:      

Office phone number:      

FPHTC Collaborative Project Application

University of South Florida – College of Public Health Florida Public Health Training Center (FPHTC)

Collaborative Project Application

Spring/Summer 2013

Form #2 (Page 2 of 3)

Desired Start Date (February 4, 2013 earliest):      

Proposed project start/end dates:      

Funds Requested*:      

DOH Location where project will be conducted:

     

*Funding is only available through August 31, 2013

Waiver

I,       , with full knowledge of my right of access to any public record made or received in connection with official public business granted by the Florida Constitution (article I, section 24) and Florida Statutes (chapter 119), expressly waive all rights whatsoever that I have to request records containing the identity of the individuals who provide written feedback on this proposal. I voluntarily agree to this waiver of my right of access to these records because I believe it will help ensure a truly candid review of my proposal by my academic peers.

Signature ___________________________________________________ Date_______________

If your project will include the use of human subjects, protected health information, live vertebrates, or biohazardous materials you must receive approval from the relevant research compliance office. Check all that apply to your project:

IRB (human subjects)       HIPAA (protected health info.)       IACUC (live vertebrates)       IBC (biohazards)      

If this scope of work is approved under another approved protocol, identify its title, PI, compliance program & approval number:      

Signature of USF COPH Faculty: ___________________________________________________________

Date: _____________________

Signature of USF COPH Student: __________________________________________________________

Date: _____________________

Signature of DOH Representative: ________________________________________________________ Date: _____________________

FPHTC Collaborative Project Application

Form #2 (Page 3 of 3)

Signatures of Collaborative Project Team and Department/Center Chair(s)

Project Leader:

_________________________________________

Department/Center Chair:

_________________________________________

Collaborative Project Team Members: Position:

_________________________________________ _________________________________________

_________________________________________ _________________________________________

_________________________________________ _________________________________________

_________________________________________ _________________________________________

FPHTC Collaborative Project Application

Form #3

PROJECT SUMMARY/ABSTRACTLimit: 200 words, double-spaced

NOTE: This word limit is strictly enforced!

Project Leader      

Title of Proposal      

Word Count      

Provide an overview of project’s need and significance in the building up the workforce in the field of Public Health and how it will aid the medically underserved. Include objectives or hypotheses, methodology, and anticipated results.

     

FPHTC Collaborative Project Application

Form #4

PROJECT NARRATIVE

Provide a description of the project, its objectives, deliverables, and timelines; highlight its uniqueness and innovations in meeting unmet needs; and explain how the project addresses a medically underserved area.

Limit: Ten double-spaced pages (12 point font, maximum 26 lines/page), inclusive of tables, figures, and explanatory footnotes. This limit does not apply to literature references as endnotes. Do NOT include appendices.

The shaded text form field below is set for 12-point Times New Roman, double spaced. If your project description includes figures or graphs you may need to adjust the font, font size, and spacing functions for the figures.

This box may be removed to provide additional space.

     

FPHTC Collaborative Project Application

Briefly describe how the proposal project identified the medically underserved communities and how the project specifically identified the gaps, which the project intends to fill. Discuss any barriers in the service area that the project hopes to overcome. This section should be no longer that one page.

Form #5

NEEDS ASSESSMENT

     

FPHTC Collaborative Project Application

Form #6

PROPOSED BUDGETSALARIES & WAGES: It is the responsibility of the Project Leader to include the current fringe benefit rates for each type of personnel as well as costs for health insurance. Please refer to http://www.research.usf.edu/sr/dsrfs.htm#FBR for this information.

Graduate students employed on the grant a minimum of .25 FTE for the duration of a funded semester/term may be eligible for a tuition subsidy.

Salaries & Fringe Benefits (list each individual/position with percentage of effort as FTE & length of employment) Amt.

Requested

SUBTOTAL OF SALARIES & WAGES; FRINGE BENEFITS $      

OTHER BUDGET ITEMSScientific or Technical Equipment (list separately each item or component or items costing $1,000 or greater) Amt.

Requested

SuppliesAmt. Requested

Travel (must be necessary to conduct the study)Amt. Requested

Operating ExpensesAmt. Requested

OtherAmt. Requested

SUBTOTAL OF OTHER BUDGET ITEMS $      

FPHTC Collaborative Project Application

TOTAL AMOUNT REQUESTED $      

FPHTC Collaborative Project Application

Form #7

BUDGET JUSTIFICATION

No word limit. Single-spaced outline format is permitted.

Clearly explain the relevance of and need for each budgeted item to the outcomes of the project. Verification with COPH will be needed to verify that this support is allowable by the sponsor.

     

FPHTC Collaborative Project Application

Form #8

BIOGRAPHICAL SKETCH

LIMIT: 2 pages per person; single-spaced outline format is permitted.

For the Faculty, Student, and DOH Representative, include an abbreviated CV with name; role in project; education (baccalaureate to last degree awarded) including institution, discipline, degree and year; current professional position; publications, projects, and/or presentations related to their role in this project including title, date, name of publication; and history of funded and pending external grants that relate to this project. A two-page Biographical Sketch in NIH or NSF format may alternatively be used here.

     

FPHTC Collaborative Project Application

Applicants should explain what data will be collected, methods for collection, and how data will be analyzed and reported. The evaluation strategy must be related to the project objectives and address the purpose of the Collaborative Project: improving the Nation’s public health systems by strengthening the technical, scientific, and managerial and leadership competence of the public health workforce.

Applicants will be required to report experience, skills, and knowledge of the project’s milestones for collecting, analyzing, and reporting performance and evaluation data. This section should be no longer than one page.

Form #9

EVALUATION

FPHTC Collaborative Project Application

Form #10

LETTER OF COMMITMENT

Submit separate paragraph for Team Member

Faculty Name:      

     

Student Name:      

     

DOH Name:      

     

FPHTC Collaborative Project Application

An explanation of each team member’s unique contributions to the project (e.g., access to equipment/materials or specialized knowledge). Please limit to one paragraph per person.