Global LMIC Cerebral Palsy Register

EXPRESSION OF INTEREST.

This form is to share the expression of interest (EOI) for establishment of a Cerebral Palsy Register and resource allocation.

Project Summary

Participating Country

Low- and middle-income countries according to the World Bank are eligible to apply. Please check if you are eligible to apply. Combined application from multiple countries is also invited.

Title

List of investigators

1. Title, First Name & Last Name

1. Role in this project

1. Affiliation

1. Email

2. Title, First Name & Last Name

2. Affiliation

2. Role in this project

2. Email

3. Title, First Name & Last Name

3. Role in this project

3. Affiliation

3. Email

4. Title, First Name & Last Name

4. Affiliation

4. Role in this project

4. Email

Focal Contact Person

Primary Contact Full Name

Primary Contact Role in this project

Primacy Contact Affiliation

Primary Contact Email

Implementing Partners

List all partners

Aims and objectives of the CP Register

Aim

Specific Objectives

Methodology

Surveillance Mechanism

Study Area/Location

Study Participants

Participant Recruitment Strategy

If other, please specify

Expected Number of Children to be Registered

Ethics Approval Status

Name of the Human Research Ethics Committee (HREC)

Study Duration

Months

Start Date

End Date

Source and Amount of Funding

Total Funding (AUD)

Source

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