Innovation Grant Application

Funded by Department of Medicine Education Committee

General Information

Investigator Full Name

Investigator Title

Investigator Preferred Email Address

Co-Investigator/Faculty Sponsor Full Name

Co-Investigator/Faculty Sponsor Title

Division

Title of Project

Needs Assessment & Literature Review

Please describe the current gap/need that your project hopes to address. If you have citations, please include a reference page in the below attachment.

250 words maximum

How will you meet this need? (Please include methods, participants, learning objectives, and learning activities as applicable)

500 words maximum

Innovation

How is your project different from those that have come before?

150 words maximum

Feasibility

Please list the stakeholders involved in your project and to what extent you have already engaged them.

(e.g. if this is a residency curriculum, have you engaged in the PD)

What is your timeline?

150 words maximum

What are your contingency plans if circumstances prevent you from carrying out your project as described?

250 words maximum

How much time do you plan to devote to this project? (must be approved by your Division Head)

Who are your collaborators?

Outcomes and Impact

How will you evaluate the impact of your project (what are your outcome measures)?

150 words maximum

What group(s) or learners will your project impact (students, residents, fellows, faculty, interprofessional learners/colleagues)?

Dissemination

What is your dissemination plan beyond DOM Grand Rounds?

150 words maximum

Budget

Total budget amount requested

Does your project budget include any technology items? If yes, please describe.

This includes any hardware, software, lab/medical equipment, or accessories that connect to the cloud or the internet.

File Upload

Attach your completed budget template. If there are any technology items included (hardware, software, anything that connects to the cloud or the internet) it must be signed by Jennifer Bonifas, DOM IT Director. If you have references cited in the literature review above, include a full list here.

Drop your files here

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