Programs or Related Information Concept Submission Form

Title of Program:

This research was funded in whole or in part by:

If funded by "Other", please describe:

Referred by:

By whom?:

Organization Name:

Lead Individual’s Name:

Street Address:

E-Mail:

Phone:

Website:
(If applicable)

(Check 4 most closely associated)

Other Topic Area:

(Check 4 most closely associated)

Other Population:

What is the purpose of this submission? (What do you hope to gain as a result of this concept submission? e.g. "Request dissemination of information about this program throughout DoD" or "Request DCoE be aware of the development of our program that shows improved outcomes for PTSD") (2000 word limit)

 

Focus of Program (e.g. What does the program do? What were the results? What are the implications for populations of interest to DCoE?) (2000 word limit)

Program/Activity components (e.g. What is used in the program? What is the program length? (e.g. 12 weeks/2 hours per week of group based treatment for Alcohol Abuse Aftercare), etc.) (2000 word limit)

Demographics (e.g. "This program assists active duty Service Members post-deployment" or "This program is for inpatient treatment of adolescent military family members ages 12-18 with mood disorders") (2000 word limit)

Current Populations already served by Program (e.g. Has program been implemented? Where/When/Outcomes, contact information of location and/or points of contact?) (2000 word limit)

Contraindications for Program (e.g. What populations are not recommended to participate in this program?) (2000 word limit)

Sustainability of the Program (e.g. How has the program been sustained over long periods?) (2000 word limit)

Accreditations (e.g. Joint Commission) (list citations, short paragraph or Not Available)

Approvals for Third Party Reimbursement (i.e. insurers who have approved)

Future activities/plans (e.g. "We will be implementing this program at _____" or "We are refining/expanding our program to _____” or "We have applied for a grant with _______.”) (2000 word limit)

Additional information DCoE should know (2000 word limit)

Please list supporting empirical evidence. If anecdotal evidence please list as such.

Randomized Controlled Studies: (citation or short paragraph for each or Not/Available)

Case Studies/Case Reports/Anecdotal Evidence: (Citation or short paragraph or N/A)

By completing the submission form, you are agreeing to have your submission reviewed by a representative of DCoE who may wish to contact you for further information related to your submission.

DCoE does not award contracts, provide research grants or offer other forms of financial support.

DCoE does not purchase programs, services or products through the concept submission process.

If you are seeking funding, please visit: http://www.usamraa.army.mil/pages/baa_forms/index.cfm

For grant announcements, please visit: www.grants.gov