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    NBRC/AMP H. Frederic Helmholz, Jr., MD

    Educational Research Endowment

    Application Information and Instructions

    The NBRC/AMP has provided an endowment to the American Respiratory Care Foundation (ARCF) to support up to $3,000 annually for educational or credentialing research, a Master’s thesis, or Doctoral dissertation with practical value to the respiratory care profession.

    General Instructions

    Submission of Application Forms

    Use the attached form to apply for the NBRC/AMP H. Frederic Helmholz, Jr., MD Educational Research Endowment. Use English only and avoid jargon and unusual abbreviations. The application should be typed, single spaced and must stay within the margin limitations indicated on the form and continuation pages. Continuation pages must be 8?” X 11”, good quality, white bond paper. Draw all graphs, diagrams, tables and charts with black ink. Do not include oversized documents, graphs, diagrams, tables and charts in the body of the application; submit them in an appendix. Mail or deliver the completed and signed original and four photocopies of the application and any Appendix materials to:

    American Respiratory Care Foundation (ARCF)

    9425 N MacArthur Blvd #100

    Irving, TX 75063-4706

    Do not submit an incomplete application. Do not submit additional material pertinent to an application after the receipt date, unless it is requested or agreed to by prior discussion with the Chairman of the ARCF Board of Trustees.

    A complete application should be submitted by June 15, 2009 for consideration of the annual award. The ARCF Board of Trustees will utilize appropriate consultants to assure a complete review of the application. Applicants will be notified by August 1 of the ARCF’s decision regarding award of a grant.

    The grant and certificate are presented at the AARC Awards Ceremony during AARC’s Annual International Congress. The ARCF will cover the travel expenses for the award recipient to attend the International Congress to receive the award.

    The ARCF reserves the right to recall funds granted for a project, if they are being misused or if sufficient progress is not being made.

    Progress Reports

    Summary reports must be submitted periodically and must be properly identified with the title and name of the principal investigator. Publications related to the research must acknowledge the support of the ARCF; five reprints of such reports must be sent to the ARCF upon publication.

    100999689.DOC Form Revised April 2002


    Application for Grant from the

    NBRC/AMP H. Frederic Helmholz, Jr., MD Educational Research Endowment

    Read Instructions Carefully

    Complete this section if an individual is applying

    Name _____________________________________________________________________________________________________________ Social Security Number _______________________________________________________________________________________________ Mailing Address _____________________________________________________________________________________________________ Position Title _______________________________________________________________________________________________________ Department, Service, Laboratory or Equivalent _____________________________________________________________________________ Major Subdivision ____________________________________________________________________________________________________ Telephone ( __________ ) _______________________

    Complete this section if an institution/organization is applying

    Institution/Organization Name __________________________________________________________________________________________ Mailing Address _____________________________________________________________________________________________________ Department, Service, Laboratory or Equivalent _____________________________________________________________________________ Telephone ( __________ ) _______________________

    Major Subdivision ____________________________________________________________________________________________________ Fiscal Officer (Name, title, address, telephone) _____________________________________________________________________________

     __________________________________________________________________________________________________________________ Official signing for Institution/Organization (Name, title, address, telephone number) ________________________________________________

     __________________________________________________________________________________________________________________ Type of Organization: • Private Nonprofit • Public (Specify federal, state or local): _____________________________________________

    All applicants must complete the following section

    Human Subjects, Derived Materials or Data Involved? • No • Yes

    Dates of Entire Proposed Project Period From: _____________________ Through: _____________________

    Performance Sites (Organizations and addresses where the project will be conducted) ____________________

     __________________________________________________________________________________________ Were any inventions conceived or reduced to practice during the course of the project? • No • Yes Principal Investigator/Program Director Assurance: I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this application.

    Signature of Principal Investigator/Program Director __________________________________________ In ink. “Per” signature not acceptable. Date

    Institution Certification and Acceptance (to be completed if other than principal investigator): I certify that the statements herein are true and complete to the best of my knowledge, and accept the obligation to comply with ARCF

    terms and conditions if a grant is awarded as a result of this application.

    Signature of Applicant Organization Official (if required) _______________________________________ In ink. “Per” signature not acceptable. Date

    100999689.DOC Form Revised April 2002

    Abstract of Research Plan

    Title of Research Project _____________________________________________________________________ Purpose (e.g., master’s thesis, doctoral dissertation or investigative research) ___________________________

    All Personnel Engaged in Project, Beginning with Principal Investigator/Program Director (Use additional pages if necessary.)

    Name: ___________________________________________ Title: ______________________________________ Dept. _________________ Name: ___________________________________________ Title: ______________________________________ Dept. _________________ Name: ___________________________________________ Title: ______________________________________ Dept. _________________ Abstract of Research Plan Concisely describe the application’s specific aims, methodology and long-term objectives, making reference to the scientific disciplines involved and the health-relatedness of the project. The abstract should be self-contained so that it can serve as a succinct and accurate description of the application when separated from it. Do not exceed the space provided.

    Practical Value Describe the practical value of the educational or credentialing research to the profession.

    100999689.DOC Form Revised April 2002

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