wellcome trust clinical phd programme application form · web viewthe overall word limit is 4000...

MRC-LSHTM West African Global Health Research Fellowship: Application Form Version: 18 July 2014

Please read the accompanying guidance before completing this form. This Application Form and the accompanying Guidance both have six Parts:

A: The Candidate C: Professional References E: Other InformationB. The Research Proposal D: Copies of Evidence F: SignatureComplete this form electronically, using Font Arial 10.

PART A: THE CANDIDATE1. Name of applicant

Given/First name Family/Surname name Title (Dr, Mr, Mrs, Ms)

2. Current contact details Please indicate which address/phone/email you prefer us to use by marking X once in each of the three rows

Home Mark X if preferre

d

Work Mark X if preferre

d

Postal

address

Phone

Email

3. Nationality

Nationality (-ies)

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4. PhD or equivalent research doctorate

Degree title, e.g. PhD, DPhil, MD

Awarding Institution Registration (Month & Year)(MM/YY)

Completion = Award) (MM/YY)

Title of doctoral Thesis

Summary of doctoral project (Maximum of 120 words)

5. Other university degrees / diplomas: (Most recent first)

Degree and Class of Degree (indicate Honours Degrees and awards given Distinctions)

Awarding Institution Registration (Year)

Completion = Award) (MM/YY)

document.docx page 2 of 18

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6. Academic prizes and distinctions: University level and above

Prize Institution Year (YY)

7. Current employment (or, if not currently employed, your most recent)

Post Institution Date started (and terminated if relevant) (MM/YY)

Current monthly salary including personal allowances (State currency)

Briefly, what is (was) your role?

Indicate the nature of your employment contract (e.g. unlimited term; fixed-term), and the termination date.

If you are not currently employed, indicate your reason for leaving

Indicate the number of months notice you would need to give to terminate your employment in order to take up this fellowship

8. Preceding employment: (Most recent first)

Position Main duties Institution Start & end dates (MM/YY)


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9. For CLINICALLY QUALIFIED applicants only, identify your chosen specialty for higher specialist training; title and dates of specialist training posts held


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10. For ALL applicants, identify any other relevant specialist training that you have undertaken, and which you have not identified in the previous sections of the application (e.g. short courses or training attachments)

Course name & date completed

Institution delivering the course

Accreditation Training outcome

11. Significant research outputs (research articles, commissioned research reports; clinical guidelines; patents granted; datasets made available to the wider research community; students supervised; public engagement: do not include conference presentations)

You should list up to five publications, published or in press (References: List all authors, title of the paper, journal, year of publication, volume and page numbers in that order. You may attach your best two publications as scanned PDFs, see Part E)

Other significant research outputs, commissioned reports (e.g. from WHO, national governments, NGOs. You may list up to five examples. Attach as PDF, see Part E)


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Conference presentations (Provide details of any oral or poster presentations at international conferences: Title of presentation/poster, Conference/meeting, Date). You may list up to five examples

12. Intended career pathway (Maximum of 150 words)

13. Relevant previous experience in African research settings, including dates: Please be specific about your role (Maximum of 300 words)


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14. Specific training needs: Identify up to three specific training needs you have, which you believe would be necessary to address for you to make the most of this Fellowship (Maximum of 50 words)


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PART B: THE OUTLINE RESEARCH PROPOSALRead the whole of Part B and the accompanying guidance before starting work on it.Word limits for each section have been indicated and should be adhered to. The overall word limit is 4000 words, excluding the words of the form itself and your 12 references.You must complete the form in Arial 10 font.

You should use sensible paragraph breaks and simple numbering and bulleting. You can also shorten or lengthen the boxes if they are too big, or small, taking account of the word limit. You may also introduce or amend a page breaks sensibly. Help the reader!Remember to work in Word but submit the document in PDF format after it is signed.If short-listed, you will be asked to update Part B, providing more detail.

15. Abstract of your proposed research project (Maximum of 250 words)

16. The title and specific aims of your proposed research project: What you want to achieve and anticipated outcomes of the project (Maximum of 200 words)

Title

Specific aims


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17. The rationale for this project: Why this project needs to be done and the potential for the project outcomes to make an impact (Maximum of 500 words)


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18. Your specific research question(s) and/or hypotheses: What you want to do (Maximum of 300 words in the Outline version. Up to 400 words in the Full Proposal)

19. Research design and strategy: How you propose to answer your research questions / test your hypotheses (Maximum of 500 words in the Outline Application. Up to 1500 words in the Full Proposal)


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20. Key assumptions, and significant uncertainties, dependencies and risks to the project (Maximum of 200 words)

21. Ethical considerations (Summary only. Details of the ethical implications of the research and the processes to obtain ethics approval is not required until after a Fellowship has been awarded) (Maximum of 150 words)


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22. Supervision, mentoring and collaboration: FULL PROPOSAL ONLY – Identify people who have agreed to help you build and sustain your Fellowship; and describe very briefly what they have agreed to do (Maximum 150 words). For a description of the role of mentor, see Paragraph 46 of the Information for WAF Applicants.

23. Indicative project plan: FULL PROPOSAL ONLY - Your milestones and roughly when you would expect to achieve them. (Maximum 200 words and one chart).


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24. Summary of resources: OUTLINE APPLICATION - Identify the main cost-generating resources that your project would need over the three years, in the following Table. You do not need to provide accurate details of monetary costs. You are expected to update and refine the figures if short-listed.FULL PROPOSAL – Provide as accurate data on costs as you are able in the following Table. Indicate roughly the percentage of the total resource that would be required in each of the three years of your project.

Budget CategoryPercentage distribution

of activity across the 3-yr project

1A. Laboratory-associated consumables and equipment (equipment under £5000 or €6000) Maximum of eight items’

Yr1 Yr2 Yr3

1B. Laboratory-associated staff (Number, % of full-time and indication of role)

Yr1 Yr2 Yr3

2A. Field and clinic-associated equipment and consumables (equipment under £5000 or €6000)

Yr1 Yr2 Yr3

2B. Field and clinic-associated staff (Number, % of full-time and indication of role)

Yr1 Yr2 Yr3

3. Access to specific research cohorts, biobanks and datasets

Yr1 Yr2 Yr3

4. Access to equipment or other items costing in excess of £(GBP)5000 or €6300, excluding transport

Yr1 Yr2 Yr3


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5. Vehicles, fuel and other transport related items

Yr1 Yr2 Yr3

6. Other major costs

Yr1 Yr2 Yr3

25. References: (A maximum of 12 references related to your proposed project)


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PART C: PROFESSIONAL REFERENCESPlease provide details of the three professional references accompanying this application (The file name should refer to a PDF file, see example in Part D).26. Institutional Statement of Support from Your Faculty or Research Dean or

Research Institution Director: The signatory should be of sufficient seniority to approve your application and, ideally, to indicate how they will continue to support your development during and (in principle) after the fellowship, if awarded to you.

Name Role Institution File name of letter accompanying this application

27. Two other professional referees:




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PART D: COPIES OF EVIDENCEList here copies all evidence that is submitted with the application, except the letters from referees listed in Part D. The file name in the right hand columns in the table below should exactly match the PDF file name.

Degree and other professional certificates

Example for fictitious candidate Dr A B Njogu

PhD

Example of file name

NjoguAB_PhD.PDF

Publications You may attach copies of two publications, indicating the file name here

Other evidence submitted with the application

PART E: OTHER INFORMATIONMark X in ONE or more boxes to indicate how you heard about this programme or indicate which national newspaper, job vacancy website, research network etc.

LSHTM website WANETAM, WAPHIR Networks

MRC Unit, The Gambia website From a professional colleague

MRC UK website Job vacancies website (Which?)

National newspaper (Which?) Other (How?)

PART F: SIGNATURE28. Outline Application


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PRINT YOUR NAME

YOUR SIGNATURE

DATE

29. Full ProposalComplete this Box only if you are submitting a Full Proposal after having been short-listed.

PRINT YOUR NAME

YOUR SIGNATURE

DATE

OUTLINE APPLICATION: The application form and accompanying documentation should be submitted as individual PDF files to Ms Mariatou Sallah, of the MRC Unit, The Gambia, by email to [email protected] so as to reach MRC by the published deadline of 16.00 hours on 24 September 2014. Applications received after the deadline will not be considered.

If you need to keep the email size down, you may submit the application form and accompanying PDFs in a batch of separate emails. In such a case, each email must be numbered uniquely and sequentially. The email text should list the name(s) of the PDFs that should be attached. A “master email” should summarise the number of emails that make up the batch.

FULL PROPOSAL: Do the same as you did for the Outline Application, by the deadline of 16.00 hours on 3 December 2014.

END OF WAGHRF APPLICATION FORM


mailto:[email protected]

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