metro south health | report cover page template web viewwe certify that research will not commence...
TRANSCRIPT
Centres for Health Research
Research Support Scheme2017 Application Form for:
Postgraduate Scholarships
Sponsored by:
CLOSING DATE: 5:00 PM MONDAY 8 AUGUST 2016
POSTGRADUATE SCHOLARSHIPS (maximum $38,000 pa) provide salary support for up to three (3) years full-time (six (6) years part-time) study towards a research higher degree. An additional $10,000 pa consumable allowance is provided for purchase of consumables.
APPLICATION INSTRUCTIONS
Refer to the 2017 Funding Guidelines when preparing your application.
Press <Tab> to move between fields.
Failure to complete any sections will deem the application ineligible.
The Applicant is required to sign the application on behalf of the research team.
SUBMISSION
Applications must be submitted electronically to [email protected]:
A signed copy of the application to be submitted as a PDF,
The application must also be submitted in Word format (signatures not required).
Files must not exceed 2 MB in size and should be named using the following naming convention:
Applicant Surname_2017 Funding Type
E.g., Smith_2017 Small
APPLICATIONS MUST BE RECEIVED BY THE CENTRES FOR HEALTH RESEARCH
NO LATER THAN 5:00 PM MONDAY 8 AUGUST 2016
LATE OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED
ENQUIRIES
Enquiries regarding the Research Support Scheme should be directed to:Research Grant Administration Officer Email: [email protected]
PA RESEARCH SUPPORT SCHEME2017 POSTGRADUATE SCHOLARSHIP APPLICATION
PROJECT TITLE(Maximum 200 characters including spaces)
DETAILS OF DEGREE
Research degree PhD Masters FTE Full time Part time at 0.00
Tertiary institution Click to select
RHD start date (actual or proposed) Proposed completion date
RESEARCH TEAMS = Student; PS = Primary Supervisor; CS = Co-Supervisor (maximum of 3)
Title Name Health profession
Organisation
S Click to choose First name Surname Click to choose Click to choose
PS Click to choose First name Surname Click to choose Click to choose
CS1 Click to choose First name Surname Click to choose Click to choose
CS2 Click to choose First name Surname Click to choose Click to choose
CS3 Click to choose First name Surname Click to choose Click to choose
ACKNOWLEDGEMENT OF SERTA GRANT PAYMENT CONDITIONS
We, [First Name, Surname] and [First Name, Surname], acknowledge and accept that grant payments from SERTA:
Can only be made to a Metro South Health (MSH) employee.
Must be deposited into a MSH research cost centre.
Signature of Applicant: Date:
Signature of Supervisor: Date:
Page 3 of 25
STUDENT/PRIMARY SUPERVISOR ELIGIBILITY CHECKLIST
To be eligible for a 2017 Postgraduate Scholarship: Primary Supervisor
Student
The Student and/or their Primary Supervisor must be able to answer Yes to questions 1 and 2 to be eligible
Yes No Yes No
1 Are you a member of staff of:
i. MSH (or hold a formal appointment to MSH)?
ii. A PAH academic partner university school or research institute based on the PAH campus (UQ SOM, UQDI, QUT IHBI)?
iii. Griffith University and based at a MSH site?
2 Will your appointment be at least 0.5 FTE for the duration of the grant?
The Student must be able to answer Yes to questions 3-5 to be eligible Yes No
3 Are you/will you be enrolled as a Research Higher Degree (RHD) candidate at UQ, QUT or Griffith University in 2017?
4 Were you /will you be enrolled as a RHD student (as outlined above) by 30 March 2017 (unless otherwise agreed upon)?
5 Is a MSH member of staff the Student or named as a CI on the application?
6 Will the majority (more than 50%) of the research activity take place at the PAH campus?
The Student must be able to answer No to questions 7-8 to be eligible
7 Do you currently hold an Australian Postgraduate Award (APA) or Postgraduate Scholarship supported by your university/institution, or any other award currently listed in the Australian Competitive Grants Register (or international equivalent)?
8 Will you have entered the third full-time year (or part-time equivalent) of your PhD studies OR final year of your Masters studies before 1 February 2017?
MANDATORY QUESTIONSLOCATION OF RESEARCH ACTIVITYProvide details of where the majority (more than 50%) of the research activity will take place (maximum 300 characters including spaces)
If the majority of the research cannot be conducted on the Metro South Health campus provide justification (maximum 300 characters including spaces)
For clinical research studies: If the MSH Governance Office has already approved the MSH site at which this study will be conducted, provide the SSA number(s)
SSA SSA/ /QPAH/ SSA SSA/ /QPAH/ SSA SSA/ /QPAH/
NOTE: Full funding of a successful clinical research application is conditional upon site specific approval being
provided by the MSH Governance Office
SSA approval letters must be sent to [email protected] for the full award amount to be received
Page 4 of 25
APPOINTMENT FRACTION AND LOCATIONProvide the FTE for each MSH/academic partner university appointment (e.g. 0.6) held by the Student and Primary Supervisor and indicate where they are based
This information will assist with determining the appropriate funding body should this application be successful
Student
MSH UQ QUT Griffith University
FTE FTE FTE FTE
PA Hospital
Beaudesert Hospital
Logan Hospital
QEII Jubilee Hospital
Redland Hospital
Community Centres
Maternity Services
Oral Health Services
Addiction and Mental Health
UQDI
SOM
IHBI
(at PAH)
PA Hospital
Beaudesert Hospital
Logan Hospital
QEII Jubilee Hospital
Redland Hospital
Community Centres
Maternity Services
Oral Health Services
Addiction and Mental Health
Primary Supervisor
MSH UQ QUT Griffith University
FTE FTE FTE FTE
PA Hospital
Beaudesert Hospital
Logan Hospital
QEII Jubilee Hospital
Redland Hospital
Community Centres
Maternity Services
Oral Health Services
Addiction and Mental Health
UQDI
SOM
IHBI
(at PAH)
PA Hospital
Beaudesert Hospital
Logan Hospital
QEII Jubilee Hospital
Redland Hospital
Community Centres
Maternity Services
Oral Health Services
Addiction and Mental Health
APPOINTMENT DETAILSProvide details of the Student’s and Primary Supervisor’s MSH and/or academic partner university appointment(s) (maximum 300 characters including spaces) E.g.: Occupational Therapist at PA Hospital; MSH provides UQ with 50% of my salary; QUT Postgraduate
Candidate based at IHBI in the Translational Research Institute
NOTE: N/A (or similar) will not be accepted
Student
Primary Supervisor
Page 5 of 25
ELIGIBILITY CERTIFICATIONWe, [First Name, Surname] and [First Name, Surname], certify that we:
Meet the relevant eligibility criteria for the Research Support Scheme.
Have answered all mandatory questions.
Signature of Student: Date:
Signature of Primary Supervisor: Date:
Page 6 of 25
1. STUDENT (APPLICANT) CONTACT DETAILS
Student name Click to choose First Name Surname
Position
Organisational department Department name
Phone numbers Primary: Secondary:
Email address
Postal address Address line 1
Address line 2
Address line 3
Suburb and Postcode
ACADEMIC QUALIFICATIONS
Qualification Awarding institution Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
RESEARCH EXPERIENCEDescribe your research experience, including projects worked on as an undergraduate student, employee or trainee (maximum 3,000 characters including spaces)
BENEFIT OF SCHOLARSHIP TO STUDENTDescribe how receiving a Research Support Scheme Postgraduate Scholarship will assist in developing your research and/or clinical career (maximum 3,000 characters including spaces)
PUBLICATIONSList publications produced in the last 5 years with ALL authors provided
Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system
1.
CONFERENCE PRESENTATIONSList research conference presentations you have delivered (maximum of 10)
Presentation type
Presentation title Conference name Location Date(s)
Click to select
Click to select
Page 7 of 25
Presentation type
Presentation title Conference name Location Date(s)
Click to select
Click to select
Click to select
Click to select
Click to select
Click to select
Click to select
AWARDS AND PRIZESList your six most significant awards or prizes obtained
Awarding body Title Type Year
---
---
---
---
---
---
OTHER SCHOLARSHIP APPLICATIONSList details of all other scholarship applications submitted in the current year
Funding body Project title Amount $
GRANTS HELDProvide details of the most relevant research funding received in the last 5 years and indicate whether the funding relates to the proposed research of this application
Funding body and type Start dateEnd date
Amount Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY] $ Yes
Page 8 of 25
Funding body and type Start dateEnd date
Amount Relevant to this application?
[DD/MM/YYYY]
No
Page 9 of 25
PRIMARY SUPERVISORPS CONTACT DETAILS
PS name Click to choose First Name Surname
Position
Organisational department Department name
Phone numbers Primary: Secondary:
Email address
Postal address Address line 1
Address line 2
Address line 3
Suburb and Postcode
PS ACADEMIC QUALIFICATIONS
Qualification Institution Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
PS ACADEMIC APPOINTMENTS
Job Title Institution
E.g., Senior Lecturer
E.g., Senior Lecturer
E.g., Senior Lecturer
PS PUBLICATIONSList publications produced in the last 5 years with ALL authors provided
Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system
1.
PS GRANTSProvide details of PS research funding received in the last 5 years and indicate whether the funding received relates to the proposed research of this application
Funding body and type Start dateEnd date
Funding amount
Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
Page 10 of 25
Funding body and type Start dateEnd date
Funding amount
Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
Page 11 of 25
CO-SUPERVISOR 1CS1 CONTACT DETAILS
CS1 name Click to choose First Name Surname
Position
MSH site Click to choose
Organisational department Department name
Phone number
Email address
CS1 ACADEMIC QUALIFICATIONS
Qualification Institution Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
CS1 ACADEMIC APPOINTMENTS
Job Title Institution
E.g., Senior Lecturer
E.g., Senior Lecturer
E.g., Senior Lecturer
CS1 PUBLICATIONSList publications produced in the last 5 years with ALL authors provided
Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system
1.
CS1 GRANTSProvide details of CS1 research funding received in the last 5 years and indicate whether the funding received relates to the proposed research of this application
Funding body and type Start dateEnd date
Funding amount
Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
Page 13 of 25
Funding body and type Start dateEnd date
Funding amount
Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
Page 14 of 25
CO-SUPERVISOR 2CS2 CONTACT DETAILS
CS2 name Click to choose First Name Surname
Position
MSH site Click to choose
Organisational department Department name
Phone number
Email address
CS2 ACADEMIC QUALIFICATIONS
Qualification Institution Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
CS2 PUBLICATIONSList publications produced in the last 5 years with ALL authors provided
Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system
1.
CS2 GRANTSProvide details of CS2 most relevant research funding received in the last 5 years and indicate whether the funding received relates to the proposed research of this application
Funding body and type Start dateEnd date
Funding amount
Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
Page 15 of 25
CO-SUPERVISOR 3CS3 CONTACT DETAILS
CS3 name Click to choose First Name Surname
Position
MSH site Click to choose
Organisational department Department name
Phone number
Email address
CS3 ACADEMIC QUALIFICATIONS
Qualification Institution Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
CS3 PUBLICATIONSList publications produced in the last 5 years with ALL authors provided
Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system
1.
CS3 GRANTSProvide details of CS3 most relevant research funding received in the last 5 years and indicate whether the funding received relates to the proposed research of this application
Funding body and type Start dateEnd date
Funding amount
Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY]
$ Yes
No
Page 17 of 25
THE PROPOSED RESEARCHTRANSLATIONAL ASPECT OF THE RESEARCH PROPOSALWhat is the translational aspect of your project?
T0 – Identification of opportunities and approaches to a health problem (basic research)
T1 – Findings from basic research tested for clinical effect and/or applicability (Phase I and II clinical trials; observational studies)
T2 – Health application to evidence based practice guidelines (Phase III clinical trials; observational studies; evidence synthesis and guidelines development)
T3 – Practice guidelines to health practices (dissemination research; implementation research; diffusion research; Phase IV clinical trials)
T4 – Practice to population health (outcomes research; population monitoring of morbidity, mortality, benefits and risk studies)
Not applicable
Definitions taken from UC San Diego Clinical and Translational Research Institute
KEY WORDSProvide up to 6 keywords that best describe the field of research
Keyword 1 Keyword 2 Keyword 3
Keyword 4 Keyword 5 Keyword 6
AIMS & HYPOTHESISProvide the aims and hypothesis for this study (maximum 1,000 characters including spaces)
RESEARCH SIGNIFICANCEDescribe the expected outcomes and benefits of the proposed study (maximum 750 characters including spaces)
RESEARCH PROPOSALProvide your research proposal on the following pages. Include background, research plan and references (maximum 4 pages including references)
NOTE: The following must be used when preparing your research proposal:
Arial font with a minimum size of 11 point (including tables, table legends and figure legends)
Line spacing of 1.5 lines
Top and bottom page margins of 2.5 cm
Left and right page margins of 2 cm
DO NOT alter headers or footers
Page 19 of 25
REVIEWER NOMINATIONSApplicants must nominate three reviewers for this application
For nominations to be eligible the Applicant must be able to answer Yes to all questionsYes No
1 Are all three nominated reviewers external to MSH and the university school(s)/research institute(s) of all named investigators?
2 Is at least one nominated reviewer from interstate or overseas?
3 Are all three nominated reviewers an acknowledged expert in the field of the proposed research (i.e. publication track record, PhD or equivalent research experience)?
4 Are all three nominated reviewers completely independent of the investigative team (including AIs) and without conflict of interest? (See section 7.1 of the 2017 Funding Guidelines)
5 Have all three nominated reviewers agreed to be available from mid-August to mid-October to assess your application?
REVIEWER 1
Name Click to choose First Name Surname
Health profession Click to choose
Organisation/Institution Organisation/Institution name
Department Department name
Phone number: Email:
Availability confirmed? Yes No
Comments (300 characters)
Who contacted this reviewer?
REVIEWER 2
Name Click to choose First Name Surname
Health profession Click to choose
Organisation/Institution Organisation/Institution name
Department Department name
Phone number: Email:
Availability confirmed? Yes No
Comments (300 characters)
Who contacted this reviewer?
Page 21 of 25
REVIEWER 3
Name Click to choose First Name Surname
Health profession Click to choose
Organisation/Institution Organisation/Institution name
Department Department name
Phone number: Email:
Availability confirmed? Yes No
Comments (300 characters)
Who contacted this reviewer?
EXCLUDED REVIEWERSIf relevant, list details of up to two reviewers you would like excluded from assessing your application and provide justification for their exclusion
EXCLUDED REVIEWER 1
Name Click to choose First Name Surname
Health profession Click to choose
Organisation/Institution Organisation/Institution name
Department Department name
Justification Provide details
EXCLUDED REVIEWER 2
Name Click to choose First Name Surname
Health profession Click to choose
Organisation/Institution Organisation/Institution name
Department Department name
Justification Provide details
Page 22 of 25
HUMAN / ANIMAL EXPERIMENTATIONRefer to the National Health and Medical Research Council’s National Statement on Ethical Conduct in Human Research (2007 updated March 2014) and/or the Australian Code of Practice for the Care and Use of Animals for Scientific Purposes (8th edition 2013)
Human Ethics Yes No N/A
Does the project involve research on human subjects?
Has ethical clearance been granted by a Human Research Ethics Committee?
If Yes, please provide the HREC clearance number:
If No, has a human ethics application been submitted?
Animal Ethics
Does the project involve research on animals?
Has ethical clearance been granted by an animal ethics committee?
If Yes, please provide the animal ethics approval number:
If No, has an animal ethics application been submitted?
NOTE: Funding of a successful application is conditional upon ethical clearance of the proposed research
Ethical clearance letters must be sent to [email protected] for funding to be received
Page 23 of 25
AGREEMENTS AND CERTIFICATION OF SUPPORTCERTIFICATION BY THE STUDENT AND PRIMARY SUPERVISORWe, [Student first name, surname] and [Primary Supervisor first name, surname], certify that written agreement (such as an email) has been obtained from all supervisors named in this Postgraduate Scholarship application and that all details provided are correct.
We understand that should this application be successful, all named Co-Supervisors on this application will be required to sign the Acceptance of Offer.
On behalf of the research team, we accept and agree to comply with the ethical standards as set out by the National Health and Medical Research Council, and any additional standards required by the appropriate Human Research/Animal Ethics Committee.
We certify that research will not commence until all ethical clearances and site specific approvals (SSAs), if required, have been obtained.
Signature of Student: Date:
Signature of Primary Supervisor: Date:
Page 24 of 25
CERTIFICATION BY HEAD(S) OF DIVISION/DEPARTMENTI certify that:
The proposed research is appropriate to the general facilities in my Division/Department and that I am prepared to have the project carried out in my Division/Department.
Experiments involving humans/animals (will) conform to the general principles set out in the National Health and Medical Research Committee’s National Statement on Ethical Conduct in Human Research/Australian Code of Practice for the Care and Use of Animals for Scientific Purposes
Name:__________________________________________________________________________________
Position: ________________________________________________________________________________
Signature:________________________________________________________ Date: __________________
Name of MSH site/university school:______________________________________________________________
Name of Head of Department/Division:_________________________________________________________
Name:__________________________________________________________________________________
Position: ________________________________________________________________________________
Signature:________________________________________________________ Date: __________________
Name of MSH site/university school:__________________________________________________________
Name of Head of Department/Division:_________________________________________________________
Name:__________________________________________________________________________________
Position: ________________________________________________________________________________
Signature:________________________________________________________ Date: __________________
Name of MSH site/university school:__________________________________________________________
Name of Head of Department/Division:_________________________________________________________
Page 25 of 25