POPLAR Project Intake Request Form

This form is currently being piloted. Please do your best to complete it. If you run into issues or are having challenges completing it, please email the POPLAR Research Coordinator at info@poplarnetwork.ca.

These are the criteria that all POPLAR projects must meet. When completing this form, please ensure that you have addressed how it fulfils these requirements:

Project Relevance: The project should be relevant to primary health care. It should have the potential to improve patient health and/or health services. Clear justification is required for the importance of the question (e.g. incidence, prevalence, costs, etc.).

Methodological Soundness and Feasibility: In terms of the methods being appropriate for the question(s), the proposed recruitment timeline, having proposed sufficient funds (and other resources) to successfully complete the project, and being ethically sound (ethics approval process must be identified, if deemed appropriate).

Study Team: A faculty member affiliated with one of the POPLAR networks should be on the team.

General Request Details

Project Title

Short Project Title

Name of Principal Investigator (PI)

Position of PI(s)

Institution/Organization of the PI(s)

Contact Email

Phone Number

Co-Investigators

POPLAR Affiliated Investigator

POPLAR Affiliated Investigator's Email

POPLAR Affiliated Investigator's Contact Number

Study Team Name (if applicable):

At which POPLAR networks would you like to conduct your research? Please select all that apply.

Alliance for Healthier Communities | Community Health Centres

SWON (Western University)

EON (Queen's University)

MUSIC (McMaster University)

NORTHH (Northern School of Medicine)

OPEN (University of Ottawa)

UPLEARN (University of Toronto)

All of the above

Support Required

What type of request are you submitting to POPLAR?

Endorsement (Letter of Support or similar)

Data Only

Clinical Research Partnership

Data plus Clinical Research Partnership

Project Description

Key Words (Insert up to 5 words)

Summary (500 words max) Describe your project . Include methods and significance to primary health care in the summary.

Estimate Project Timeline

Funding and Costs

How is the project being funded?

No Funding

Grant: Please specify in text box below

Contract: Please specify in text box below

Industry Partnership: Please specify in text box below

Other: Please specify in text box below

Please specify how this project is being funded:

Are there any commercial benefits from this research to you, your organization, or other organizations?

Please list potential conflicts of interest, if any.

What is the provisional budget for POPLAR support? Please attach budget justification at the end of the form.

Ethics and Operationalization

Please select the appropriate Ethics status for your project:

Ethics approval obtained

Pending ethics approval

Not applicable (e.g. letter of support, waiver) please specify:

Please specify which REB has approved the project/submitted to:

Will a consent by patient or family physician be required?

Yes

Are there any risks associated with this research (to patients or broadly to primary care)?

Dissemination

Do you plan to publish the results?

Yes

If results are not to be published, how will the results be made available in the public domain?

Other

Please upload a single document with the following: a. Completed or draft study protocol for the project.

b. Any applicable details specifying objective and methods including study protocol covering multiple analyses, REB approval letters, waivers, budget justification, budget breakdown or any other relevant details.

If you experience any issues trying to upload the file, please email the POPLAR Research Coordinator at: info@poplarnetwork.ca

Please upload a single file in PDF or MSWord here up to 1000MB.