Voucher Application

Rural Pilots Voucher Request Form

Apply for a $25,000 award. Please complete the fields below as appropriate.

This program is designed to support activities or proposals that evaluate innovative digital health methods for participant engagement and recruitment in hard-to-reach patient populations. Voucher requests should include plans to utilize services within Virginia Commonwealth University Health System (VCUHS) including the MCV campus and ambulatory care facilities throughout Virginia, VCU Health Community Memorial Hospital (CMH), Children’s Hospital of Richmond (CHoR) at VCU, Brook Road campus, and VCU Health Tappahannock.

Selected reviewers will evaluate each application and make a determination on the award status. You will be notified once a decision has been made.

Thank you.

Questions? Please contact ruralpilots@vcu.edu

First Name

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Last Name

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Office Phone Number

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Cell Phone Number

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School

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Other School

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Department

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Other Department

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Chair - First Name

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Chair - Last Name

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Chair - Email

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FA - First Name

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FA - Last Name

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FA - Email

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Other Funding Source 1

Other Funding Source 2

Other Funding Source 3

Is this an initial application or a resubmission?

Initial Application

Resubmission

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Progress Report

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Study Title

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Do you have IRB approval for this research?

Yes

IRB submitted, not yet approved

Not Applicable

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IRB Number

IRB Approval Letter

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Project Narrative

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Upload format requirements:
.doc or .pdf file; at least 0.5" margins; 11-point Arial font; single spaced. Submissions that fail to comply with all the requirements may not be reviewed.

Please upload your research plan. Make sure your study design describes what digital health methods you will be using, how you plan to recruit patients specifically in rural areas and/or hard-to-reach- populations, and how the initiative will lead to more rural patients being enrolled.

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VCUHS or core facilities/resources to be utilized

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Please upload your proposed budget for this project

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PI Biosketch

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Appendix (optional)

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