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Nursing and Midwifery Research FellowshipsApplication Form
2014
Applications close 5:00 pm AEST 30 January 2015
Applicant’s name:
Nursing and Midwifery Research Fellowships Application Form
Published by the State of Queensland (Queensland Health), December 2014
This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au
© State of Queensland (Queensland Health) 2014
You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health).
For more information contact:Health and Medical Research, the Department of Health, GPO Box 48, Brisbane QLD 4001, email [email protected], phone +61 (0) 7 3328 9503.
An electronic version of this document is available at http://www.health.qld.gov.au/ohmr/html/rpu/proj_grants.asp
Disclaimer:The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information.
1. Application instructionsBefore completing this form, please ensure that you have read all relevant documentation outlined below.
Health and Medical Research (HMR), Preventive Health Unit, the Department of Health will call for applications from 8 December 2014. This application will be assessed by an expert review panel against the selection criteria at Section 7. The panel is comprised of expert representatives from nursing and midwifery backgrounds.
1.1 Submission of application
Nursing and Midwifery Research Fellowship submission
Step It is recommended that applicants:
One Read the Nursing and Midwifery Research Fellowships Funding Rules
www.health.qld.gov.au/ohmr/documents/nurse_fundrules.pdf
Two Read Nursing and Midwifery Research Fellowships Legal Requirements 2014
www.health.qld.gov.au/ohmr/documents/nurse_legal.pdf
Three Complete this application form (Nursing and Midwifery Research Fellowships Application Form)
www.health.qld.gov.au/ohmr/documents/nurse_appl.doc
Four Submit application to [email protected]
1.1.1 Application formAll applications must be submitted using this form (as per format at Section1.1.3)
1.1.2 Closing dateApplications are to be submitted to the [email protected] email account by 5pm AEST 30 January 2015. Late applications will not be accepted.
If applicants have difficulty submitting applications, please contact the Department of Health on telephone +61 7 3328 9503 to make alternative arrangements.
1.1.3 Format of lodgementThe application will be submitted in a single Adobe Acrobat Portable Document Format (.pdf). Please ensure that the software used is compatible with version 11 of Adobe Acrobat.
Applicants will submit their application on this form using:
Nursing and Midwifery Research Fellowships Application Form 1
Arial 10.5 point
Single-spaced font
2 cm page margins.
The application form must be submitted in its original form. Applicants are not permitted to edit the underlying template of the application form.
1.1.4 Naming the fileThe following naming convention should be used in the document file name (do not include spaces) – the surname and first name refers to the Chief Investigator (CI):
HMR_NurseMid_SURNAME_FIRSTNAME.PDF
1.1.5 CertificationApplicants have the option of submitting the final signed certification page as part of their application (preferred), or as a second separate attachment with the file name – the surname and first name refers to the CI:
Cert_HMR_NurseMid_SURNAME_FIRSTNAME.PDF
2. Nursing and Midwifery Research Fellowship categories
Please indicate below the category of Nursing and Midwifery Research Fellowship that you are applying for. Please note that as a CI, you are only eligible to apply for one of the following four research fellowships.
Novice Research Fellowship (2 research fellowships are available at a maximum of $10,000 per research fellowship over 12 months)
Early-Career Research Fellowship (2 research fellowships are available at a maximum of $15,000 per research fellowship over 12 months)
Experienced Researcher Fellowship (1 research fellowship is available at a maximum of $60,000 per annum for 2 years: a total of $120,000 per research fellowship)
Research Implementation Fellowship (2 research fellowships are available at a maximum of $60,000 per annum for 2 years: a total of $120,000 per research fellowship)
Nursing and Midwifery Research Fellowships Application Form 2
3. Personal details of Chief InvestigatorPersonal details of Chief InvestigatorFamily name
Given name(s)
Title (Prof, Dr, Mr, Mrs, Ms etc)
Gender Male/Female
Postal address
Suburb/town
State
Postcode
Country
Courier address (Line 1)
Courier address (Line 2)
Suburb/town
State
Postcode
Country
Work phone number
Facsimile number
Mobile phone number
Email address (contact is via email in the first instance)
Secondary mail address
Nursing and Midwifery Research Fellowships Application Form 3
Citizenship/resident details of Chief InvestigatorCitizenship
Primary place of residence
If not an Australian citizen, please indicate if you are a permanent or temporary resident, or hold a Special Category Visa (please provide certification copies of relevant documentation).
If not a holder of the above, has a residency permit or a Special Category Visa been sought? Please provide details.
Equal employment/diversity information – please indicate if you (the Chief Investigator) identify with any of the following groups. The completion of this section is voluntary.
People with a disability Yes/No
People from a non-English speaking background
Yes/No
Aboriginal Yes/No
Torres Strait Islander Yes/No
Australian South Sea Islander
Yes/No
4. Qualifications of Chief InvestigatorAcademic/research qualifications – Copy and paste the table below as many time as requiredAcademic qualification (e.g. BNurs, MSN, PhD)
Institution
Year
Topic/Majors
Clinical qualifications – Copy and paste the table below as many times as requiredProfessional Qualification (e.g. certificate, FACN)
Institution
Nursing and Midwifery Research Fellowships Application Form 4
Year
Clinical registrations – Copy and paste the table below as many times as requiredClinical registration type (e.g. general)
Professional body and jurisdiction
Registration number
Status (eg current)
5. Current appointments of Chief InvestigatorCopy and paste the table below as many times as required for each separate appointment. Please include any relevant clinical, research or academic appointments.
Current appointments and research appointment/sJob title (e.g. Clinical Nurse, Research Fellow)
Organisation (e.g. Metro North Hospital and Health Service)
Location (e.g. Royal Brisbane and Women’s Hospital)
Current status of position (eg permanent full time/temporary full time/part time/contract)
Nursing and Midwifery Research Fellowships Application Form 5
6. Proposed area of researchTo assist in providing appropriate peer review for your application and for statistical and reporting purposes, please provide the most appropriate descriptors from the lists provided by the National Health and Medical Research Council (http://www.nhmrc.gov.au/grants/policy/keywords.htm).
Area of researchBroad research area Select only 1 area
Field of research Select only 1 field
Research keywords/phrases
Select at least 3 but no more than 5 research keywords/phrases
Socio-economic objective Select at least 1 but no more than 5 objectives
Plain English summary Provide up to five sentences that best encapsulate the research in lay terms (this may be used by the Department of Health in promotions and/or media releases).
Does your application address one of the National Health Priority Areas (NHPAs)? (see section 5, Funding Rules). If yes please specify which NHPA your application addresses.
7. Selection criteria 1 – Research quality 40% for all four categories of research fellowships
In your answers, please ensure you address the selection criteria in Section 7 of the Nursing and Midwifery Research Fellowships Funding Rules.
7.1 Research planLocation of researchIn this section, include where the research will be undertaken, e.g. university or hospital (maximum 50 words)
Title of research project (maximum 100 words)
Nursing and Midwifery Research Fellowships Application Form 6
Brief background/literature reviewIn this section, include the current knowledge in your proposed field of research and highlight any gaps in the knowledge (maximum one page)
Aims and rationale of research (maximum five sentences)
Research hypothesis (maximum five sentences)
Brief methodology In this section, include relevant technologies, statistical and analytical methods (maximum one page)
Assistant investigator/s In this section include all key team members/assistant investigator/s. Copy and paste the table below as many times as required.
Name
Job title
Place of employment
Role in project team
Percentage contribution of team member
Briefly describe the benefit of the collaboration
Expected outcomesWhat outcomes are sought from the project and how will they be measured? (maximum one page)
Nursing and Midwifery Research Fellowships Application Form 7
In the section below, describe the proposed milestones for the research fellowship.
Ensure the milestones are focused to achieve the desired outcomes.
If the application is successful, the completion of milestones will be addressed in the progress reports.
Do not include:
Writing grant applications
Applying for and obtaining ethics approvals and governance authorisation – this is mandatory prior to beginning any research project
Recruitment of staff
Attendance at conferences or symposia.
MilestonesBriefly outline the proposed milestones for the project and the dates by which they are expected to be completed. Insert as many additional rows as necessary.
Milestone 1 Insert date by which milestone is expected to be completed
Milestone 2 Insert date by which milestone is expected to be completed
8. Selection criteria 2 – Significance and/or innovation
25% for experienced researchers and research implementation applicants; 40% for novice researcher and early-career researcher applicants
Describe the originality of the research and the potential importance or impact of the project on the field (maximum one page).
Describe the project vision for Queensland (maximum one page)This may include (but is not limited to) the means by which the funding of the project will:
address areas of need regarding the health of Queenslanders lead to improved patient outcomes, through innovation or the implementation
or change to guidelines or policies (ie translation into practice) facilitate new dimensions of leadership, training, team building, collaboration
and leverage of external funds integrate with your research and contribute to improved research culture and
clinical practice in Queensland’s publicly funded health care facilities.
Nursing and Midwifery Research Fellowships Application Form 8
9. Selection criteria 3 – Track record of Chief Investigator
25% for experienced researchers and research implementation applicants; 10% for novice researcher and early-career researcher applicants)
Researchers applying as a novice nurse/midwife researcher will not be assessed on their track record, rather their ability to undertake research, including a good support network, sound project idea and methodology, and good understanding of the research area.
Evaluation of this selection criterion is also based on the track record of the identified mentor and their ability to support a novice researcher. As a novice researcher, please ensure you provide any relevant details regarding your track record first,then provide details of your mentor’s track record.
9.1 Publications
In the section below, list your most significant publications from the last five years, which are relevant to this research application.
Please describe, in one or two sentences, the significance of your top five publications.
Publications could include:
peer-reviewed research papers
patents applied for or granted
reviews, letters, notes
books or book chapters
technical or other reports, including non-peer reviewed technical reports that have had an impact on policy, practice or commercialisation
inquiries, other journal contributions
conference abstracts/proceedings.
List your most significant publications relevant to this research application (maximum two pages)
Nursing and Midwifery Research Fellowships Application Form 9
9.2 Key conferences and meetings participation
In the section below, list your most significant participation in key conferences and meetings, which are relevant to this research application.
Participation may include (but is not limited to):
Keynote addresses
Presentations
Involvement on relevant committees.
Participation in key conferences and meetings (maximum one page)
9.3 Major research grantsList any major research grants you have received in the last five years (maximum one page)
9.4 Career disruptionsOutline any significant career disruptions lasting longer than six months that have affected your ability to undertake hospital and health service/clinical duties or academic research over the last five years. Examples include pregnancy and childbirth, major illness, career responsibilities, parental leave, and industry or other work placements where research was not able to be conducted. Applicants should nominate periods where their career has been disrupted and provide a brief explanation of the reason.
Nursing and Midwifery Research Fellowships Application Form 10
9.5 Leadership and training
In the section below, briefly outline your involvement in both research and clinical/hospital and health service duties leadership and training. Dot points are acceptable.
This may include (but is not limited to):
Involvement in leadership, training and mentorship
Involvement in supervision of clinical staff
Supervision of research staff (indicate level of students – honours, Masters, PhD, postdoctoral)
Any courses or training that you have undertaken that has directly contributed to your research work.
Research leadership and training (maximum half page)
9.6 Achievements, prizes and awards for research and clinical/hospital and health service duties
Outline any significant prizes, honours or peer-recognition you have received for research relevant to this application. Please include the name and brief details of the award. Dot points are acceptable. (maximum one page)
9.7 Other professional activities and community involvement
Outline any further significant professional activities and community involvement that is relevant to this research proposal. Dot points are acceptable. (maximum half page)
10. Selection criteria 4 – Budget 10% for all four categories of research fellowships
Outline your budget for the proposed project, including justification (value for money) for each line item (maximum one page).Budget may include any direct research costs, including research assistants, contract statisticians or other relevant experts, payment for services required such as pathology, administrative costs directly associated with the research project, travel,
Nursing and Midwifery Research Fellowships Application Form 11
and accommodation for data collection.
11. Identification of research mentor (for applicants applying under the novice researcher category only)
Applicants in the novice researcher category who do not have a research mentor will not be considered.
Research mentorTitle Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Research field
Academic qualifications
Clinical qualifications
Institute Hospital/university etc
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact Yes/No
12. Identification of novice researcher team member for applicants applying under the experienced researcher and research implementation category
Novice researcherTitle Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Clinical qualifications
Nursing and Midwifery Research Fellowships Application Form 12
Institute Hospital/university etc
Office phone number
Mobile phone number
Email address
13. External assessorsThe Department of Health reserves the right to appoint external assessors. These external assessors may be provided with relevant documentation to complete the assessment.
List a maximum of three name(s) below, of any people to be excluded from the external assessment process where relevant (ie because of a significant conflict of interest).
Excluded external assessors (if relevant)
14. RefereesApplicants are required to contact and seek agreement from two referees to comment on the Nursing and Midwifery Research Fellowship application. Please include the contact details and the relationship of the referees to the CI (eg ‘current manager’). It is preferred applicants provide referees that currently work closely with the applicant. If possible, provide one clinical referee and one research referee.
Referee 1Title Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Postal address
Postal address
Suburb/town
State Hospital/university etc
Postcode
Country
Office phone number
Nursing and Midwifery Research Fellowships Application Form 13
Mobile phone number
Email address
Relationship to applicant
Permission to contact Yes/No
Referee 2Title Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Postal address
Postal address
Suburb/town
State Hospital/university etc
Postcode
Country
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact Yes/No
15. CertificationApplicants have the option of submitting the final signed certification page as part of their application (preferred), or as a second separate attachment using the following naming convention for the file name
Cert_NurseMid_SURNAME_FIRSTNAME.PDF
15.1 Chief Investigator certificationI, the applicant, certify that all details given in this application are correct
Applicant’s certification
Nursing and Midwifery Research Fellowships Application Form 14
Title Prof, Dr, Mr, Mrs, Ms etc
Last name Applicant's last name
First name(s) Applicant's first name
Signature
Date [DD/MM/YYYY]
15.2 Assistant investigator certificationAssistant investigator’s certification (copy and paste the table below as many times as required)
Title Assistant investigator's title
Last name Assistant investigator's last name
First name(s) Assistant investigator's first name
Signature
Date [DD/MM/YYYY]
15.3 Research mentor certification (for applicants applying for the novice researcher category only)
I, agree to act as a research mentor for [insert applicants name] should the applicant be awarded a Nursing and Midwifery Research Fellowship in the novice researcher category.
Research mentor certification Title Research mentor's details
Last name Research mentor's details
First name(s) Research mentor's details
Signature
Date [DD/MM/YYYY]
15.4 Novice researcher certificationThis certification is to be completed by:
novice researchers on research implementation and experienced researcher teams
Nursing and Midwifery Research Fellowships Application Form 15
and
by all assistant investigators on novice researcher teams.
I, [insert novice researcher's name] confirm that I am a novice researcher should the applicant be awarded a Nursing and Midwifery Research Fellowship.
Novice researcher certification Title Novice researcher's details
Last name Novice researcher's details
First name(s) Novice researcher's details
Signature
Date [DD/MM/YYYY]
15.5 Early-career researcher certificationThis certification is to be completed by all assistant investigators on early career researcher teams.
I, [insert early career researcher's name] confirm that I am an early-career researcher, should the applicant be awarded a Nursing and Midwifery Research Fellowship.
Early career researcher certification Title Early-career researcher's details
Last name Early-career researcher's details
First name(s) Early-career researcher's details
Signature
Date [DD/MM/YYYY]
Nursing and Midwifery Research Fellowships Application Form 16
Department of HealthNurseMid – Applicaton form3 – 05.11.14www.health.qld.gov.au
Nursing and Midwifery Research Fellowships Application Form 17
