For official use: Research proposal number _____________________ ANNEXURE 2	PROPOSAL SUMMARY

ANNEXURE 2 PROPOSAL SUMMARY
Name of Institution/organisation conducting research
Name of Investigators
Postal Address
Telephone Number
Fax number
Mobile Number
Email Address
Institution which gave ethical approval
Date of Ethical approval
Date research expected to commence
Proposed data collection dates at requested facilities
Date research expected to end
Date research reports should be expected
Western Cape Districts where research will be done: (Please mark with an X )	Metro Westcoast Cape Winelands Overberg Central Karoo Eden
WC DOH Facilities where research will be done: (Please list the name of the facility under appropriate category)	Tertiary Hospitals: District Hospitals: Community Health Centres: Clinics:
Other facilities in the WC DOH where research will be done (Please specify)	Psychiatric Hospitals: TB Hospitals Other: Databases :
Research title
Research aim
Research objectives
Key Words
Brief description of methodology (Please specify estimated sample size and duration of contact with each participant e.g. interview length, clinical exams)
Type of Study Design: e.g. Case Control, RCT, Survey
Budget for research
Source of funding for the research
The research will have implications for the requested facilities regarding:	Yes or NO	If Yes what are these implications and how does your project plan to mitigate the impact
Additional load on nursing
Support services
Consumables
Laboratory tests
Equipment
Space
Communications
Additional OPD visits
Admission of patients
How will the sites be prepared to participate in your research?
Results dissemination plan Tick which groups will be affected by your research findings	Provincial managers □ District Directors □ Facility manager and staff □ Patients □ Community □ Other (please specify) _________________________
2. What is the earliest date or time frame from the end of research collection that the feedback (at least the minimum requirements*) will be expected? * Minimum research findings feedback template	Within one month □ Within one to three months □ Within three to six months □ Longer than six months □