Metro South Health | Report Cover Page template Web viewWe certify that research will not commence until all ethical clearances and site specific approvals (SSAs), if required, have

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]

mailto:[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



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:

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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

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mailto:[email protected]

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


Redland Hospital

Community Centres

Maternity Services



Primary Supervisor

MSH UQ QUT Griffith University

FTE FTE FTE FTE

PA Hospital

Beaudesert Hospital

Logan Hospital


Redland Hospital

Community Centres

Maternity Services



UQDI

SOM

IHBI

(at PAH)

PA Hospital

Beaudesert Hospital

Logan Hospital


Redland Hospital

Community Centres

Maternity Services



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

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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:

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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

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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

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Amount Relevant to this application?

[DD/MM/YYYY]

No

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PRIMARY SUPERVISORPS CONTACT DETAILS

PS name Click to choose First Name Surname

Position


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



PS PUBLICATIONSList publications produced in the last 5 years with ALL authors provided



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 amount

Relevant to this application?

[DD/MM/YYYY]

[DD/MM/YYYY]

$ Yes

No

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Funding amount


[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

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CO-SUPERVISOR 1CS1 CONTACT DETAILS

CS1 name Click to choose First Name Surname

Position

MSH site Click to choose


Phone number

Email address

CS1 ACADEMIC QUALIFICATIONS


DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

CS1 ACADEMIC APPOINTMENTS

Job Title Institution




CS1 PUBLICATIONSList publications produced in the last 5 years with ALL authors provided



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 amount


[DD/MM/YYYY]

[DD/MM/YYYY]

$ Yes

No

[DD/MM/YYYY]

[DD/MM/YYYY]

$ Yes

No

[DD/MM/YYYY]

[DD/MM/YYYY]

$ Yes

No

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Funding amount


[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

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Position



Phone number

Email address



DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR




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 amount


[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

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Position



Phone number

Email address



DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR




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 amount


[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

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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

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Delete this text and insert the research proposal here

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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









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REVIEWER 3









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





Justification Provide details

EXCLUDED REVIEWER 2





Justification Provide details

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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

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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:

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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:__________________________________________________________________________________

Position: ________________________________________________________________________________

Signature:________________________________________________________ Date: __________________

Name of MSH site/university school:__________________________________________________________


Page 25 of 25

Documents

Metro South Health | Report Cover Page template Web viewWe certify that research will not commence until all ethical clearances and site specific approvals (SSAs), if required, have