Sir Charles Gairdner and Osborne Park Health Care Group Research Advisory Committee

2018-19 Ray Florence Shaw GrantExceptional care from dedicated people – We put patients first

APPLICATION INSTRUCTIONS

The Sir Charles Gairdner Osborne Park Health Care Group (SCGOPHCG) in collaboration with the Ray Florence Shaw Trust are offering funding for short-term research projects in cardiovascular or ophthalmology research to be conducted at the SCGOPHCG.

The conditions of funding are as follows:Cardiovascular research-to promote the advancement of knowledge and training within the Hospital by means of study and research into the cause and prevention of diseases of the heart and blood vessels and without limiting the generality of the foregoing the diagnosis, treatment and prevention of coronary artery disease, myocardial infarction, cardiac arrhythmias and valvular heart disease.

Ophthalmology research-to promote the advancement of knowledge and training within the hospital by means of study and research into the cause and prevention and treatment of diseases of the eyes and without limiting the generality of the foregoing the diagnosis, treatment and prevention of the retinal disease, glaucoma, the pathology of scarring in the eye, studies in corneal tissue typing, keratorefractive surgery, laser treatment, tissue culture, therapeutic diagnostic and surgical modalities, clinical medical and surgical ophthalmology, optics, electrophysiology of the eye and the pharmacology of drugs used in eye treatment

In 2018/19 one grant each for cardiovascular and ophthalmology research of up to $30,000 are available to researchers employed at the Sir Charles Gairdner Osborne Park Health Care Group for at least 0.25 FTE. Applications must be fully completed to be accepted. Final decisions regarding funding will be made by the Ray Florence Shaw Trustees.

The Application Form must be typed in Arial font 11 point or larger.

Acknowledgment of receipt of application will be provided via e-mail.

Queries regarding the application process should be directed by email to the scgh.grants@health.wa.gov.au or Telephone: (08) 6457 4531

ONE electronic copy is to be emailed to the Department of Research as a single Microsoft Word file, including signatures (signature pages may be included as separate documents) by the closing date above.

Please note: The decision of the Committee is final.

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 1

Applications Close: 3:00pm Friday 12th JanuaryLATE OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

RESEARCH GRANT APPLICATIONS

SECTION 2: PROPOSED PROJECT

Coordinating Principal Investigator

Project title

Lay TitleThis should be understandable to someone who has no knowledge of the subject matter

Amount requested must not exceed $30,000

$

Project summarySummarise your research questions, methodology, predicted benefits for WA Health. Please make this understandable for a lay audience.

(Maximum 300 words)

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 2

SECTION 3: RESEARCH TEAM

(i) Coordinating Principal Investigator (all correspondence will be sent to this person)

Title, First Name, SURNAME

Postal addressCorrespondence will be sent to this address

Telephone number(s)

Email address

Research Discipline Cardiovascular☐ Ophthalmology ☐

Position held

CGNM Number (This will be used to check your appointment with SCGOPHCG)

% FTE employed at SCGOPHCG

SCGOPHCG Department and Location

Highest qualification

Role in this project

(ii) Other Research Team Members (where applicable)

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In addition to the Coordinating Principal Investigator listed above, please provide details for each Principal Investigators, Associate Investigators and Research Personnel for the project. Please insert additional tables as required.

Principal Investigator 1 – will be the next point of contact after the CPI

Title, First Name, SURNAME

Position held

Institution and Location

Email address

Role in this project

Principal Investigator 2 – please add additional tables if required

Title, First Name, SURNAME

Position held

Institution and Location

Email address

Role in this project

Associate Investigators

Associate Investigator 1– please add additional tables as required

Title, First Name, SURNAME

Institution

Telephone number(s)

Email address

Role in this project

Other Research Personnel, e.g. students, administration staff, lab staff

Title, First Name, SURNAME Contribution Qualification

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 4

SECTION 4: ETHICS AND INSTITUTIONAL APPROVALSIt is the responsibility of the CPI to ensure that all appropriate approvals, guidelines and requirements are met. If the research grant is successful, evidence of ethical and institutional approvals must be provided.

SECTION 5: GRANT REVIEWERSPlease submit the names and current email addresses of four appropriate Interstate and/or International grant reviewers

All reviewers must:(i) Have the relevant expertise to review this application(ii) Not be currently collaborating with the CPI on any research projects.(iii) Should not have been nominated to review a previous application from the CPI

within the past 2 years

1Name:Department:Email Address:

2Name:Department:Email Address:

3Name:Department:Email Address:

4Name:Department:Email Address:

Please note: The Committee will carefully consider any discrepant reviews.

The decision of the Committee for funding is final.

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 5

SECTION 6: DETAILS OF PROJECTS(Maximum THREE pages)

(i) Hypothesis and Aims

(ii) Background and Research Plan

(iii) Significance of this research

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 6

SECTION 7: BUDGETPlease note N/A for any section of the budget that is not relevant and in-kind may be notedCPI must ensure that:

(i) All codes must be provided for their budgetDetails

Staff (including level’s, number of staff, hours per week and on-going costs e.g. RA level 4, 0.5 FTE + Admin Staff at G3, 1 FTE etc) Cost

Account Code

1st Quarter $2nd Quarter $3rd Quarter $4th Quarter $What is your justification for the above Staffing

Equipment Give full details items over $5,000 CostAccount Code

1. $2. $What is your justification for the above Equipment:

Animals Required (including species and the number required) CostAccount Code

$What is your justification for the above Animals

Maintenance Supplies (plastic, stationery, reagents, service contract etc) Cost

Account Code

1. $2. $3.What is your justification for the above Supplies

Other Costs CostAccount Code

1. $2. $What is your justification for the above Other Costs

Total Amount Requested for this Project $

The above break-down of your budget must equal the amount you have requested

All budget items must include account codes for items, To locate these account codes refer to the Chart of Accounts, available through the following link http://hcn-intranet.hdwa.health.wa.gov.au/portal/page?_pageid=118,82455&_dad=portal&_schema=PORTAL&p_countr=&p_lang=

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 7

SECTION 8: CERTIFICATION BY RESEARCH TEAMAs Coordinating Principal Investigator I confirm that:

1. All information contained within this application is correct

2. I have discussed my project in full with my Head of Department or Divisional Director

3. That this is the only application that I have submitted for Ray Florence Shaw grant funding.

If this application is successful I undertake to ensure that this research project:4. Will meet the terms to all SCGOPHCG Research Advisory Committee Grant

Guidelines and Requirements

5. Will obtain all relevant Ethical and Institutional approvals

HREC and institutional approvals - https://rgs.health.wa.gov.au/Pages/Home.aspx

AEC- http://www.research.uwa.edu.au/staff/animals/ethics-committee6. Will be conducted as per the National Statement on Ethical Conduct in Human

Research (2007) and national research standards as set out by the National Health and Medical Research Council and the Therapeutic Goods Administration http://www.nhmrc.gov.au/research/index.htm

7. Will fulfill all obligations/undertakings as is required by the SCGOPHCG Research Advisory Committee

8. Will participate in any public relations as requested by the Sir Charles Gairdner Osborne Park Health Care Group to promote the grants and/or research at Sir Charles Gairdner Osborne Park Health Care Group

I accept that if I fail to complete my duties as a condition of receiving the grant, I may be excluded from future Research Advisory Committee Grants.

Coordinating Principal InvestigatorFull Name

Signature Date

Principal Investigator 1

Full Name

Signature Date

Principal Investigator 2

Full Name

Signature Date

Note: If more than two Principal Investigators, please insert additional tables as required.

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 8

SECTION 9: CERTIFICATION BY HEAD OF DEPARTMENT I certify that:

a) The above project proposed by _____________________________ ______ (Coordinating Principal Investigator) is acceptable and appropriate to the Department and I am prepared to have the project carried out in this area; and

b) That this project has my full approval and supportc) That this project will have no significant impact upon my Departments Operational

Budget or resources d) I am responsible for notifying the Research Advisory Committee of any changes to

the project, should anything impact upon the Coordinating Principal Investigator doing so

Title, First Name, SURNAME

Position

Institution

Signature

Date

Telephone number(s)

Email address

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 9

SECTION 10: CURRICULUM VITAEPlease insert Curriculum Vitae of the Coordinating Principal and Principal Investigators. It is requested that an abridged version only be provided, with an upper limit of TWO pages each, including key publications from the last 5 years.___________________________________________________________________

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 10

SECTION 11: CITED REFERENCES ___________________________________________________________________

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 11

SECTION 12: CHECK LIST

Prior to submitting the application, the Coordinating Principal Investigator should check that they have completed the following requirements:

1. Identified relevant approvals or agreements that are requiredNote: All governance approvals (including ethics approval) must beforwarded before commencement of project

2. Attached CVs (limited to 2 pages each) of the Coordinating Principal Investigator and each Principal Investigator

3. Signed the Application Form, and obtained the signature of each Principal Investigator

4. Obtained approval and the signature for the Head of Department or Divisional Director

5. Removed the INSTRUCTIONS page from the APPLICATION FORM for electronic and hard copy submission

6. Emailed the completed application (including CVs and quotes) in ONE Microsoft Word file by the closing date toscgh.grants@health.wa.gov.au

7. Provided one copy with signatures to scgh.grants@health.wa.gov.au

SCGOPHCG RFS Annual Funding – 2018/19 - Application Form 12