Research Application Form

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This field is for validation purposes and should be left unchanged.

Your Name*

Phone number*

Phone Type*

Home
Cell
Work

Email*

Does your research aim to improve the experience of aging?*

yes
no

Research Project Title*

Principal Investigator*

Other Researchers*

Purpose of the Research*

Recruitment Guidelines*

What age or other criteria must participants meet?

Research Methods / Participant Activities*

What will participants be asked to do as part of the research?

Recruitment Strategy*

How do you plan to recruit participants?

Do you plan compensation or incentive for participants?*

yes
no
to be determined

Anticipated Research End Date*

Anticipated Research Start Date*

Do you need research space on Warm Hearth Campus?*

yes
no
to be determined

If yes, describe space needs, frequency and scheduling needs*

IRB Status*

approved
pending
not submitted yet
exempt

IRB Institution, protocol number, approval, expiration date*

Is research contingent on grant-funding not yet awarded?*

yes
no
partially

Expected funding-decision date*

Does your research budget include funds for Warm Hearth staff time or facility use?*

yes
no
to be determined

If funding is not awarded will the project proceed?*

yes
no
to be determined

If we agree to become a partner, Warm Hearth expects ongoing updates about funding, timeline, design, recruitment and status. We request an exit interview at the end of recruitment activity and a presentation of the research or appropriate deliverable. We ask that you notify us of any publications or public findings. Is your team willing to meet these communication and closeout expectations?*

yes
no

Additional information or quetstions

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