Request for Support - Sepsis Canada

Sepsis Canada Support Request Form (For Members)

Sepsis Canada Support Request Form (For Members)

Please note, the deadline to submit this request form to Sepsis Canada is 10 business days before the documentation demonstrating Sepsis Canada support is required. Please submit one request for per project.

Section 1.0 General Information

Project Title: *

Full Name of Principal Applicant: *

Full Names of Main Co-Applicant(s):

Principal Applicant Email Address: *

Principal Applicant Telephone Number: *

Principal Applicant Position (eg. Professor): *

Principal Applicant Department: *

Principal Applicant University or Institutional Affiliation: *

Is the Principal Applicant a member of Sepsis Canada? *

Please note, the Principal Applicant or Co-Applicant must be a member of Sepsis Canada to receive support.

Is the Co-Applicant a member of Sepsis Canada? *

Please note, the Principal Applicant or Co-Applicant must be a member of Sepsis Canada to receive support.

Which Sepsis Canada Team does this project best align with (if support is provided by Sepsis Canada, the project will become part of that team): *

Is this project new to Sepsis Canada? *

Name of Grant Competition (if applicable):

Grant Submission Deadline (if applicable):

Attach a Summary of the Research Project that will help us determine if the proposed research addresses the Suspect Sepsis, Save Lives, Support Recovery vision. Maximum length: 1 page *

This information will be shared with the appropriate Sepsis Canada Committees and the relevant Team Leads.

Attach a lay abstract that can be used to explain your project to the general public. If supported by Sepsis Canada, this information may be posted on the Sepsis Canada website. Maximum length: 1 page *

The lay abstract, can be the same as your ResearchNet Lay Abstract.

Section 2.0 Request for Support

Indicate how Sepsis Canada can support your research and provide the requested details.

Patent Partner Support - Would you like help to find patient partners to engage in research related to sepsis? *

Additional Information

Patient Partner Compensation - Please indicate the number of patient partners that you are looking to collaborate with.

We can provide up to $250 per project, to support the integration of a patient partner onto your research team (10 hours, $25 / hour). If your research team is applying for funding, you are encouraged to include a line item in your budget to compensate patient partners for their time and participation in the project moving forward.

Training Support - We can provide support to your team by giving them access to the Sepsis Canada training program. Please indicate the number of trainees that will be accessing the training program.

The training program is a two-year program and includes webinars and journal clubs, a structured mentorship program and attendance at the annual symposium (valued at $3,000 in kind).

Communications Support - We can help researchers communicate their r esearch by disseminating research related communications via our newsletter, social media platforms , space on our website and presentation at the Sepsis Canada annual symposium. *

Administrative Support - Sepsis Canada can provide administrative support from our staff in - kind (eg. Managing Director or Communications Coordinator ). Provide a description of the resources needed from our network and how this will help your team.

Small Meeting Support - We can help coordinate small research meetings as part of the Sepsis Canada annual symposium and can help cover the costs of meeting space and the AV (in kind). Please indicate purpose, size and timing of your proposed meeting.

Clinical Research Network Support - We can provide your site access to a searchable database , which includes information on the data and biological specimens participating in the clinical research network. *

Examples of how this information can be used includes assessing sites when launching a new research program, assessing the productivity of current research program, or creating progress reports for funding bodies.

We can conduct a needs assessment and offer a tailored capacity - building plan to your site if you are interested in participating in the Sepsis Canada Clinical Research Network.

Additionally, we will monitor the implementation of the capacity - building plan at your site.

Collaboration Support - We can facilitate introductions and foster collaboration between members in our research network. Please indicate who you would like to collaborate with, or what expertise or discipline you are looking to collaborate with.

This can include researchers, health care providers, patient partners and trainees. We can also facilitate introductions with international sepsis researchers.

Section 3.0 Additional Information