An ISO 9001:2008 Certified Hospital
MOI TEACHING AND REFERRAL HOSPITAL
INTRAMURAL RESEARCH FUND – FY 2016-2017
APPLICATION FORM
PRINCIPAL INVESTIGATOR:
RANK / TITLE:
DEPARTMENT:
PERSONAL FILE NO (PF.):
MOBILE NO:
EMAIL:
ADDRESS
PHYSICAL ADDRESS WHERE WORK WILL BE PERFORMED:
CO-INVESTIGATOR / COLLABORATOR (INDICATE N/A IF NOT APPLICABLE):
RANK / TITLE:
DEPARTMENT and SCHOOL:
INSTITUTION / AFFILIATION:
ADDRESS:
EMAIL:
TITLE OF PROPOSAL:
TOTAL AMOUNT REQUESTED: KSH:
From:
TOTAL.
TOTAL PROJECT PERIOD:
(Day/Month/Year)
To:
(Day/ Month/Year)
(not exceeding ksh. 1million)
YES
NO
PENDING PROTOCOL
IREC APPROVAL /OTHER
ETHICAL CLEARENCE
1
#
APPROVAL
DATE
REQUIRED APPLICANT AND INSTITUTION SIGNATURES
“The undersigned applicant agrees to accept responsibility for the scientific, fiscal and technical
conduct of the project and for provision of required progress reports if the grant is awarded as the
result of this application. I understand that any future application are contingent on successful
completion of this project unless a specific request for exception is made and approved.”
(If additional investigators from a single institution are involved, please insert a duplicate signature
block for applicable investigator, department and/or school signatures.)
INSTITUTION
SIGNATURE
Name of Applicant :
Name of Department Head / Chair:
Name of Senior Manager:
(limited to S.A.D and above)
2
DATE
PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR NAME (LAST, FIRST, MIDDLE):
FROM
DETAILED BUDGET FOR TOTAL BUDGET
(Day/Month/Year)
PERIOD
DIRECT COSTS ONLY
PERSONNEL (Applicant organization only)
ROLE ON
PROJECT
NAME
TYPE
APPT.
(months)
THROUGH
(Day/Month/Year)
%
EFFORT ON
PROJECT
Principal
Investigator
Collaborator
KENYA SHILLING AMOUNT
REQUESTED
TOTAL
SUPPLIES
TRAVEL
PATIENT CARE COSTS
OTHER EXPENSES
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD
BUDGET JUSTIFICATION (1 and1/2 pages):
Note - this page may be copied and a separate budget included for each participating site
3
3
PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR NAME
(LAST
FIRST
MIDDLE)
PROJECT SUMMARY / ABSTRACT (Provide a brief summary (300- 400 words) describing
the project focus, its significance, expected outcomes, international partner, and proposed plans
for the expansion of future research if pilot funding is awarded)
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4
PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR NAME
(LAST
FIRST
MIDDLE)
RESEARCH PLAN/PROJECT DESCRIPTION (No more than 6 pages, single-spaced, Times
Roman 12-point font, and 0.5 inch margins excluding references. See application guidelines for
specifics):
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PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR NAME
(LAST
FIRST
MIDDLE)
PROPOSED PROJECT TIMELINE AND MILESTONES (Describe the timeline for all
major components of the project including descriptions of key milestones)
6