JEFFERSON PUBLIC CITIZENS
Program Application for 2016-17 Projects
Jefferson Public Citizens (JPC) aims to inspire students to act as engaged
citizens through active community partnerships, research service projects, and
scholarly reflection. JPC encourages and prepares students to work with local,
national and international communities to effect positive change in the world.
Deadline:
Tuesday, December 1, 2015
12:00 PM (noon)
Late or incomplete applications will NOT be accepted.
PREPARE THE FOLLOWING APPLICATION MATERIALS:
Available at: http://www.virginia.edu/jpc/important_material.html
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I. Cover Sheet
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II. Project Proposal
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III. Budget
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IV. Preliminary Work Plan
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V. Team Members
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VI. Faculty Advisor
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VII. Community Partner
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VIII. ISO Student Projects Abroad Form (If applicable)
Every team member is required to fill out a copy of this section and obtain a copy of their
current academic transcript (unofficial).
Obtain a letter of recommendation from your faculty advisor
Obtain a letter a letter of endorsement from your community partner.
Submission Procedure:
SAVE YOUR APPLICATION MATERIALS AS ONE ADOBE PDF AND UPLOAD TO THE
JEFFERSON PUBLIC CITIZENS COLLAB SITE (Adobe Pro software for combining
files is available in the Scholars Lab).
a. Name your file in this format: “LastnameFirstname.pdf” of lead student
b. Go to the uvacollab site link here
(https://collab.itc.virginia.edu/portal/site/bdb697c0-3f5d-4f60-9519bb95ee906bb6) and join the JPC application Collab site.
c. Complete and then submit the application.
Direct any questions to Brian Cullaty at 434-924-3306 or [email protected]
I. COVER SHEET
Project
Title:
Geographic Location: ¨ Local
¨ National
¨ International
Has this project been funded previously? ¨ Yes ¨ No
Faculty Advisor (must be a full time teaching and research faculty member)
Name:
Department:
UVa E-mail Address:
Community Partner
Organization:
Contact Person:
E-mail Address:
Has your group been invited into the community to conduct your project? ¨ Yes ¨ No
Team Members
* List lead student contact first
Name
Major
Year
UVA ID #
UVa E-mail
ID
Department/Program
Year
UVA ID #
UVa Email
ID
*
Graduate Mentor Team Member
(if applicable)
II. PROJECT PROPOSAL
Project Abstract
This text will be used for promotional purposes on the JPC website and other publications.
(50-75 words)
Introduction, Background, and Research Question
Introduce your topic and identify the problem. Discuss any relevant literature (there is additional
space for bibliographic references at the end). This section must include a research question or
hypothesis for your project.
(Maximum 300 words)
II. Project Proposal
Methodology
Describe your research methods. What data will you collect and how will you do so? How will you
analyze the data? Why are these the appropriate methods for your project? What are the limitations
of your research methods?
(Maximum 300 words)
Anticipated Outcomes
Explain the anticipated outcomes of your JPC research service project, including:
• The service component of your project
• The impact of the project on the community
• The production of new knowledge
• How you will share the findings with your community partner
(Maximum 100 words)
II. Project Proposal
References
Provide bibliographic information for any published work referenced or cited.
II. Project Proposal
Continuation of a Previous JPC Project
If this is a continuation of a previous JPC project, please provide the following:
Previous Project Title:
Year of Project:
Faculty Advisor:
Team Members:
Outcomes
Describe the outcomes of the previous JPC project. What did the group accomplish? How were
outcomes measured?
(Maximum 100 words)
How is the new project proposed different from the previous project?
(Maximum 100 words)
II. Project Proposal
III. ANTICIPATED BUDGET
BUDGET ITEM
ITEMIZED COSTS
SUBTOTAL
I. Project Expenses (up to $3,000 per team member)
A. Transportation
For example:
Plane tickets, bus tickets, train tickets, taxi fares, car
rental, car Insurance, gas
Trip cancellation insurance
Public transportation
Visa fees
B. Living
Rent, Hotel or housing accommodations,
Food, Meals
C. Medical
Immunizations
Medications & prescriptions related to travel (e.g.
malaria)
Medical evacuation insurance
D. Other
IIa. Project Materials and Supplies (purchased by the
team)
For example:
Printing, copying
International cell phones
Translators
Transcribers
Training or workshop fees
Small thank you gifts for hosts
Hospitality for community events
Equipment
IIb. Project Material and Supplies (purchased by your
faculty advisor’s department; maximum total request
for section IIa and IIb combined may not exceed
$5,000)
For example:
Lab supplies, field equipment, lab materials and
equipment
Building equipment
TOTAL AMOUNT
REQUESTED
Maximum=$20,000
For your planning, please note that project funds are disbursed on June 1. Please append a narrative for any
part of your budget you would like to explain further. You may also reformat and attach as a separate page. III. Anticipated Budget
IV. PRELIMINARY WORK PLAN
A detailed series of questions prompting the development of a work plan can be found on the JPC
website: http://www.virginia.edu/jpc/docs/JPCProjectWorkPlan.pdf. Briefly summarize a preliminary
work plan using the chart below as a guide. Format the chart to suit your project and attach as a
separate page.
ACTIVITIES
OUTCOMES
(DELIVERABLES)
IMPLEMENTATION
STEPS
PROJECT
TIMELINE,
DATE TO BE
COMPLETED
GOALS &
OBJECTIVES
TEAM
MEMBER
RESPONSIBLE
RESOURCES
NEEDED
Work Plan adapted from Tufts University, January 2009.
IV. Preliminary Work Plan
V. TEAM MEMBERS
Each member of your team including the graduate mentor team member must complete a copy of this
section, sign the endorsement, and submit an unofficial copy of a current academic transcript.
Project Title:
Name:
Student ID #:
Cellphone:
Academic Advisor (Department’s Director of Graduate Studies for Graduate Mentor):
Academic Advisor’s E-mail Address:
Statement of Purpose
Describe your role on this team and what you expect to contribute to this proposed JPC project.
Include any prior community engagement and service, related coursework, and/or participation in
workshops, lectures, and special training.
(Maximum 200 words)
Goals
Please list three learning goals for yourself that you hope to reach by the end of the JPC project:
Please three goals you have for the JPC project:
V. Team Members
Team Member Endorsement
Please initial each of the following statements and sign below:
I will be a fulltime undergraduate or graduate student enrolled at the University of Virginia through the
2016-17 academic year. __________
I promise to adhere to all JPC Award procedures, including the submission of my mid-term report,
final project, and presentation. __________
If the project involves human and/or animal subjects, I will seek advice from my faculty advisor, and I
will comply with the policies of the University’s Institutional Review Boards. __________
If the proposed JPC project involves international travel, I understand that:
I may not travel to any location with a U.S. State Department Travel Warning and, if such a warning is
issued while I am abroad, I must leave the country immediately in the safest manner possible.
(http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html). Prior to my departure, I will register with the
International Studies Office, attend a pre-departure orientation, and comply with any other ISO
requirements. www.virginia.edu/iso. __________
I am responsible for obtaining a visa and/or work or other permit required for my intended destination.
__________
I am responsible for getting appropriate inoculations and overseas health/emergency
coverage.__________
If I am an international student, I will consult with an international student advisor about my visa
status. __________
_______________________________________________________________
Signature of JPC Team Member
____________________________________
Date of Signature
Insert an unofficial copy of your current academic transcript behind this page.
V. Team Members
VI. FACULTY ADVISOR
Your JPC Faculty Advisor must read and initial the following statements and sign below.
I agree to advise following proposed JPC project:
(Insert Project Title)
I approve the proposed JPC Project budget and will work with the students on the financial
management and fiscal responsibilities of their project. __________
If the project involves human and/or animal subjects, I will advise my students to comply with the
policies of the University’s Institutional Review Boards. I understand that I also may be required to
undergo online IRB training. __________
If the project involves international travel, I will advise my students to register with the International
Studies Office, submit the Travel Form For Student Research And Service-Learning Abroad, attend a
pre-departure orientation, and comply with any other ISO requirements. __________
I will review the team’s final project and submit a final academic evaluation of the JPC project to the
Office of University Community Partnerships when requested. __________
I understand that I will be asked to participate in meetings or events related to the JPC program
including the students’ final presentations. ___________
1) Please state the research question this project is seeking to answer:
2) Please list three goals that you want the students to accomplish by the end of the project. These
can be accomplishments of the team in terms of their own learning, research process, overall project
success, and/or products or impact for the community.
.
_______________________________________________________________
Signature of Faculty Advisor
____________________________________
Date of Signature
JPC asks that the faculty advisor also write a letter of recommendation. Please insert the letter behind
this page.
VI. Faculty Advisor
VII. COMMUNITY PARTNER
Community Partner Organization:
Website:
Address:
Community Partner Contact Person:
Title:
Phone Number:
Email:
What is your understanding of the time commitment needed from the students (hours per day, days
per month)?
What are your expectations for how the JPC students can help your organization achieve its goals?
JPC requests that your community partner organization write a letter of endorsement for your
proposed project, ideally on organizational letterhead (if your partner is not in the U.S., this letter may
be submitted in the body of an e-mail). Please insert the endorsement letter behind this page.
VII. Community Partner
VII. COMMUNITY PARTNER
Community Partnership Agreement
The following statements affirm the responsibilities for each of the parties involved in this community
partnership. Checkboxes and signatures, below, confirm that each partner has read, understood and accepted
this agreement.
JPC Team:
□ We will respect and abide by the community organization’s guidelines and policies.
□ We will respect and abide by all applicable guidelines, policies, and procedures of the University of Virginia.
□ We will discuss any school holidays or breaks with the community partner before the start of the project, and
we will notify him/her if we must be late or absent.
□ We understand our commitment to the organization and the community partner, and we will be dependable.
□ We understand the expectations and goals of the project we will complete.
□ We will address challenges and/or concerns with our faculty advisor and the community partner.
□ We will maintain efficient and consistent communication with the organization and our faculty advisor as
agreed upon.
□ We will meet with the community partner and faculty advisor in order to receive feedback throughout our
work.
□ We will complete any necessary evaluation at the end of our project.
□ We understand and agree that assignments made pursuant to the JPC and this agreement involve
unavoidable risk, despite the best efforts of the University of Virginia to provide for our health and safety, and
we hereby assume all reasonable risk associated with our participation in the JPC.
Signature of lead student contact:___________________________________
Date signed: _________________
Community Partner:
□ I will provide an orientation to the organization, and I will be clear about my expectations.
□ I will give appropriate time and effort to effectively collaborate with the students, and I will give feedback as
appropriate.
□ I will address challenges and/or concerns with the students and the UVa faculty advisor.
□ I will maintain efficient and consistent communication with the students and the UVa faculty advisor as
agreed upon.
□ I will complete any necessary evaluation at the end of the students’ project.
Signature of Community Partner Contact Person:___________________________________
Date signed: _________________
UVa Faculty Advisor:
□ I will maintain an open relationship with the organization and community partner.
□ I will give appropriate time and effort to effectively advise the students, and I will give feedback as
appropriate.
□ I will address challenges and/or concerns with the student and the community partner.
□ I will maintain efficient and consistent communication with the student and community partner as agreed
upon.
□ I will complete any necessary evaluation at the end of the project.
Signature of Faculty Advisor:___________________________________
Date signed: _________________
Agreement adapted from Tufts University, January 2010
VII. Community Partner
VII. RESEARCH PROTOCOLS
Institutional Review Board If your proposed JPC project will involve working with human or animal subjects, your work may be
subject to approval by the Institutional Review Board (IRB). The IRB ensures the university’s
compliance with federally mandated research guidelines. If awarded, your JPC proposal will be
forwarded to the IRB and you will receive a message indicating whether your proposed project will
require an IRB submission. If so, you MUST submit an IRB protocol form. For more information on
the IRB, we strongly encourage you to watch a brief presentation available online at:
http://www.virginia.edu/vpr/irb/learningshots/Undergraduate_Research/player.html
¨ This JPC Project will involve working with human or animal subjects.
If yes, and you are awarded JPC funding, your project will be forwarded to the IRB for review.
International Travel
If your proposed JPC project will involve international travel, you will need to complete: 1) the
International Studies Office’s (ISO) Travel Form For Student Research and Service-Learning Abroad
(a two page pdf form) and 2) an online registration. The purpose of these forms is to help your group
reflect on and prepare for the unique conditions, opportunities and challenges of proposing to conduct
a JPC research and service project outside of the United States. Knowing that you may not have all
the details of your project at this time, we ask that you provide as much information as possible. Your
responses will also be considered during the review of your JPC project application. In addition to
answering several questions about preparing for a JPC project abroad, you will need to supply your
travel dates and travel destination at time of online registration. Start your application one week in
advance to ensure yourself sufficient time to complete the form. See:
http://www.programs.studyabroad.virginia.edu/?go=ZMTspa
¨ This JPC Project will involve travel abroad.
If applicable, please insert an International Studies Office Travel Form for Student Research and
Service-Learning Abroad behind this page.
Additional Funding
Please indicate if you are applying for other grants to support this project.
¨ Center for Global Health Grant
¨ Double Hoo Award
¨ Miller Center Grant
¨ Institute for Practical Ethics Internship
¨ College of Arts & Sciences Small Research Grant
¨Undergraduate Award for the Arts
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Harrison Award
Echols Research Grant
Kenan Award
Raven Fellowship
Community-Based Grant
Other (please list)
VII. Research Protocols