1 I. COVER SHEET Project Title: Geographic Location: Local National International Has this project been funded previously? Yes No Faculty Advisor 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 Graduate Mentor (Graduate Mentors complete a separate application, but please complete the below if this project includes the participation of a graduate mentor.) Name: Department: UVa E-mail Address: Team Members * List lead student contact first Name Major Year * UVA Computing ID I. Cover Sheet
2 II. PROJECT PROPOSAL Project Abstract This text will be used for promotional purposes on the JPC website and other publications. (50-75 words) Thesis Statement State the research question or the hypothesis of your project. (50-75 words) Introduction Introduce your topic and identify the problem. Discuss any relevant literature (there is additional space for bibliographic references at the end). (Maximum 200 words) II. Project Proposal
3 Methodology Describe your research methodology. Who/what will you study? How has your site and/or population been identified? What data will you collect and will you do so? How will you analyze the data? What are the limitations of your research methods? (Maximum 200 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
4 References Provide bibliographic information for any published work referenced or cited. II. Project Proposal
5 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
6 III. BUDGET BUDGET ITEM ITEMIZED COSTS SUBTOTAL I. Stipends for Team Members (up to $3,000 per team member) II. Travel Expenses 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 Hotel or housing accommodations Food C. Medical Immunizations Medications & prescriptions related to travel (e.g. malaria) Medical evacuation insurance III. Project Materials and Supplies For example: Printing, copying Internet access, software International cell phones Translators Transcribers Training or workshop fees Small thank you gifts for hosts Hospitality for community events Physical equipment Building materials TOTAL AMOUNT REQUESTED (Maximum=$30,000) For a sample budget see: http://www.virginia.edu/jpc/docs/samplejpcbudget.pdf III. Budget
7 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. GOALS & OBJECTIVES ACTIVITIES OUTCOMES (DELIVERABLES) IMPLEMENTATION STEPS PROJECT TIMELINE, DATE TO BE COMPLETED TEAM MEMBER RESPONSIBLE RESOURCES NEEDED Work Plan adapted from Tufts University, January 2009. IV. Preliminary Work Plan
8 V. TEAM MEMBERS Each member of your team must complete a copy of this section, sign the endorsement, and attach an unofficial copy of a current academic transcript. Project Title: Name: Student ID #: Cellphone: Academic Advisor: 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) V. Team Members
9 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
10 Team Member Endorsement Please initial each of the following statements and sign below: 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
11 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
12 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
13 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
14 VIII. 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.virginia.edu/jpc/docs/2011-12-internationaltravelformguide.pdf) 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 Harrison Award Echols Research Grant Kenan Award Raven Fellowship Community-Based Grant Other (please list) VIII. Research Protocols