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WCH FOUNDATION
2016 MATTHEW SCRIVERPICU NURSES SCHOLARSHIP
APPLICATION FORM Application1. PERSONAL DETAILSNAME:Title / First Name /Surname
2. CONTACT DETAILSPostal/Delivery Address:(incl. floor / level / building)
Department / Division:
Telephone (work): Mobile:
Email:
3. CURRICULUM VITAE (short Personal CV – to be included as an attachment to this application)This should include (amongst other relevant info):3.1 Education3.2 Employment history3.3 Awards3.4 Research experience – Include completed research projects, research grant achievement and brief
summary of research projects3.5 Publications3.6 Presentations
4. OUTLINE OF RESEARCH PROJECT 4.1 TITLE OF THE RESEARCH PROJECT
4.2 NAME OF DEPARTMENT (WCHN department in which the research work will be undertaken)
4.3 ABSTRACT OF THE RESEARCH PROJECT: in lay terms (300 words or less)
4.4 BRIEF DESCRIPTION OF THE RESEARCH PROJECTNB: (4 pages or less), should include research objectives, recruitment and consent (if applicable), research methods, data analysis and interpretation techniques, the significance of the study for paediatric health care in a PICU setting.
4.5 PROJECT FINDINGSOutline where and in what format the applicant is aiming to publish and/or present the project findings
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4.6 NAME OF THE PROPOSED SUPERVISOR(S)Supervisor 1Name:(Title / First Name / Surname) Department/Division: Telephone (work): Mobile: Email:
Supervisor 2Name:(Title / First Name / Surname) Department/Division: Telephone (work): Mobile: Email:
4.7 PROPOSED COMMENCEMENT DATE
5. DEPARTMENT LETTER OF SUPPORT
A letter from the Head of the Department, supporting the application, and confirming that the Department can provide appropriate facilities and supervision for the proposed research, should the application be successful – to be included as an attachment to the application.Letter Attached: YES NO
6. REFEREE REPORTSThe applicant must request a written report from two (2) referees. This report should include the referees’ name, address, and contact details and outline the applicant’s abilities and personal suitability to undertake the proposed research project.
Reports may be forwarded by the closing date: 4pm Monday 18 January 2016 in hard copy to: The Matthew Scriver PICU Nurses’ Scholarship, C/- Research Secretariat, Level 2, Samuel Way Building, Women’s and Children’s Health Network, 72 King William Road, NORTH ADELAIDE SA 5006 or via email to [email protected]
REPORT ATTACHED: YES / NO
REFEREE AName:(Title / First Name / Surname)
Postal/Delivery Address: (include: Floor / Level / Building)
Department /Division:
Telephone (work): Mobile: Email:
REFEREE BName:(Title / First Name / Surname)
Postal/Delivery Address: (include: Floor / Level / Building)
Department /Division:
Telephone (work): Mobile: Email:
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7. ETHICAL/SAFETY CLEARANCES refer http://www.wch.sa.gov.au/research/committees/index.html to check clearances requiredPlease note:It is the responsibility of the applicant to provide notification of clearances to the Research Secretariat before the research commences.If this application has a different title from that which is on the ethical/safety clearance, you MUST provide a statement to the relevant committee stating that the protocol is identical and requesting that the new title be added.Approval for your project will not been granted until written confirmation is received from the relevant ethics/safety committee.
Approval required
Approval attached
Approval number
Animal Ethics Committee
Yes
No
Yes
No
If no approval, has application been submitted: Yes/No
If no, when will you submit: / /
Human Research Ethics Committee
Yes
No
Yes
No
If no approval, has application been submitted: Yes/No
If no, when will you submit: / /
Institutional Biosafety Committee
Yes
No
Yes
No
If no approval, has application been submitted: Yes/NoIf no, when will you submit: / /
8. BUDGETDetail how the money ($3,000) will be spent and state any costs which will and/or may be met from other sources e.g. Departmental support etc.
9. OTHER INFORMATIONThe applicant should provide any other information which may help in the assessment of the application.
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10. CERTIFICATIONAll applications are to be signed, dated and endorsed, as outlined below, by the Applicant, Department Head, Divisional Director and Executive Director.
APPLICANTSignature: ________________________ Date: _____________
Endorsement of Application
DEPARTMENT HEADAcknowledging consent and support for the application and budget provision during the Scholarship
Name: _______________________________________________
Signature: ________________________ Date: _____________
DIVISIONAL DIRECTORName: _______________________________________________
Signature: ________________________ Date: _____________
EXECUTIVE DIRECTORName: _______________________________________________
Signature: ________________________ Date: _____________
11. SUBMITTING APPLICATION11.1 The applicant is required to submit:
a) One original signed (hard copy) of application form, with all relevant attachments (CV, Supporting letter and referees letter).
b) Plus Four (4) photocopies of the application (with all relevant attachments included).
NB: The application form must be typed and not hand written and addressed to:
The Matthew Scriver PICU Nurses’ ScholarshipC/- Ms Katherine McPhail,Research Grants Officer, Research SecretariatLevel 2, Samuel Way Building,Women’s and Children’s Health Network72 King William RoadNORTH ADELAIDE SA 5006
11.2 An electronic copy of the application is required (and must be a Word document), and should be sent to: [email protected] (no signatures are required on the electronic copy).
Applications must be submitted by: 4.00pm Monday, 18 January 2015
NB: Late applications WILL NOT be accepted.
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