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Junior DoctorResearch Fellowships Application Form
Round Two2016
Applications close 12 noon AEST 8 August 2016
Applicant’s name:
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Junior Doctor Research Fellowships Application Form
Published by the State of Queensland (Queensland Health), April 2016
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) 2016
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 Unit, the Department of Health, GPO Box 48, Brisbane QLD 4001, email [email protected], phone +61 (0) 7 3328 9833.
An electronic version of this document is available at www.health.qld.gov.au/ohmr/html/rpu/junior-research-fellowships.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 Unit (HMRU), Healthcare Innovation and Research Branch, the Department of Health will call for applications in June 2016. This application will be assessed by an expert review panel against the selection criteria at Section 6 of the Junior Doctor Research Fellowship Funding Rules. The review panel is comprised of representatives from medical and research backgrounds.
1.1 Submission of application
Junior Doctor Research Fellowship submission
Step It is recommended that applicants:
One Read the Junior Doctor Research Fellowships Funding Rules 2016www.health.qld.gov.au/ohmr/html/rpu/junior-research-fellowships.asp
Two Read Junior Doctor Research Fellowships Legal Requirements 2016www.health.qld.gov.au/ohmr/html/rpu/junior-research-fellowships.asp
Three Complete this application form (Junior Doctor Research Fellowships Application Form)
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 12noon AEST 8 August 2016. Late applications will not be accepted.
If applicants have difficulty submitting applications, please contact the Department of Health on telephone +61 7 3328 9833 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:
Arial 10.5 point
Single-spaced font
2 cm page margins.
Junior Doctor Research Fellowships Application Form (Round Two)1
The application form must be submitted in its original form by the junior doctor. Applicants are not permitted to edit the underlying template of the application form.
Submissions require completion of this application form. Where there is no response to a question, please indicate ‘not applicable’.
1.1.4 Naming the fileThe following naming convention should be used in the PDF document file name (do not include spaces) – the surname and first name refers to the applicant:
HMR_Junior_SURNAME_FIRSTNAME.PDF
1.1.5 AttachmentsApplicants should include their Curriculum Vitae and official academic transcript in one PDF attachment with the file name – the surname and first name refers to the applicant:
Attach_HMR_Junior_SURNAME_FIRSTNAME.PDF
2. Personal details of applicant Personal details of applicantFamily 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
Junior Doctor Research Fellowships Application Form (Round Two)2
Postcode
Country
Work phone number
Applicant’s mobile phone number
Email address (contact is via email in the first instance)
Secondary mail address
Citizenship/resident details of applicantCitizenship
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 certified 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 applicant) 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
3. Qualifications of applicant Academic/research qualifications – Copy and paste the table below as many time as requiredAcademic qualification (e.g. BSc, MSc, PhD)
Junior Doctor Research Fellowships Application Form (Round Two)3
Institution
Year
Topic/Majors
Medical status Medical Practitioner registration number
Current appointment level (e.g. JHO, PHO)
Other health profession registration/s (e.g. Nurse, Physio) and registration number
4. Current appointments of applicant Copy and paste the table below as many times as required for each separate appointment.
Current appointments and research appointment/sJob title (e.g. Doctor, Research Fellow)
Organisation (e.g. Metro North Hospital and Health Service)
Location (e.g. Royal Brisbane and Women’s Hospital)
Current status of position (e.g. permanent full time/temporary full time/part time/contract)
5. Other Research Funding Awarded or Requested
Acceptance of a Junior Doctor Research Fellowship may impact on the continuance of other research funding already held and/or requested. Please detail below all current or requested research funding. Please indicate if any of this funding would need to be relinquished if successful in gaining a Junior Doctor Research Fellowship.
Current or requested research funding
Junior Doctor Research Fellowships Application Form (Round Two)4
6. Nominated Mentor and Supervisor Applicants for Round Two must nominate a mentor and a supervisor to provide guidance for and management of their Fellowship. Applicants must choose a mentor and a supervisor.
A mentor is a person who has significant experience in the development and implementation of research that is relevant to the Fellowship. The mentor is expected to provide guidance of a strategic nature through all stages of the Fellowship. The Fellow’s mentor must reside and conduct research activities in Queensland.
A supervisor is a person who has experience in the development and implementation of research that is relevant to the Fellowship. The supervisor is expected to provide an active management role through all stages of the Fellowship on a day to day basis. The Fellow’s supervisor must reside and conduct research activities in Queensland.
Mentor and supervisor details are to be provided in the appropriate sections below. Mentor and supervisor acceptance and certification are to be provided in Section 10 of this Application Form.
Mentor detailsTitle Prof, Dr, Mr, Mrs, Ms etc
First name, surname
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
Junior Doctor Research Fellowships Application Form (Round Two)5
Supervisor detailsTitle Prof, Dr, Mr, Mrs, Ms etc
First name, surname
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
7. Fellowship engagementPlease nominate your preference for engagement in the Junior Doctor Research Fellowship Program below.
Fellowship Participation
Full-time Part-time No Preference
If part-time please indicate % time for Fellowship Participation: %
(Note that a 50% minimum participation is required)
8. Selection Criteria and Referees Applications are assessed by the review panel, according to three assessment criteria as outlined in Section 6 of the Junior Doctor Research Fellowship Funding Rules.
8.1 CV and Academic TranscriptInclude a CV and copy of your official academic transcript in PDF format.
Junior Doctor Research Fellowships Application Form (Round Two)6
8.2 Rationale for applying for a Junior Doctor Research Fellowship
Include a rationale on why you want a Junior Doctor Research Fellowship (not more than 500 words) and how your experience and track record make you an ideal candidate.
In your rationale include your preference for start date for your fellowship if you are successful. This must be no later than 30 January 2017.
Outline why you want a Junior Doctor Research Fellowship and how your experience and track record make you an ideal person for a Fellowship (Arial 10.5 point, single-spaced font)
9. RefereesApplicants are required to include contact details (email and phone number) of two referees. You must seek approval prior to nominating a person as a referee. Referees should have a thorough knowledge of your work performance and conduct, and it is preferable to include your current/immediate past supervisor. By providing the names and contact details of your referees you consent for these people to be contacted by the selection panel.
Referee 1Title Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Name of employing organisation
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact Yes / No
Junior Doctor Research Fellowships Application Form (Round Two)7
Referee 2Title Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Name of employing organisation
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact Yes / No
10. CertificationI, the applicant, certify that all details given in this application are correct
Applicant’s certificationTitle Prof, Dr, Mr, Mrs, Ms etc
Last name Applicant's last name
First name(s) Applicant's first name
Signature
Date [DD/MM/YYYY]
I, agree to act as a Mentor for [insert Applicant's name] should the Applicant be awarded a Junior Doctor Research Fellowship.
Mentor’s certification Title Mentor's details
Surname Mentor's details
First name(s) Mentor's details
Signature
Date [DD/MM/YYYY]
Junior Doctor Research Fellowships Application Form (Round Two)8
I, agree to act as a Supervisor for [insert Applicant's name] should the Applicant be awarded a Junior Doctor Research Fellowship.
Supervisor’s certification Title Supervisor's details
Surname Supervisor's details
First name(s) Supervisor's details
Signature
Date [DD/MM/YYYY]
11. Checklist before submissionBefore submitting your application you must confirm that you have:
Completed each section of the application form
Certifications section signed using original signature.
Application document (including signed certification) included in the one PDF format file using the naming convention: HMR_Junior_SURNAME_FIRSTNAME.PDF
Attached curriculum vitae and academic qualifications (certified copy of official transcripts) in the one PDF format file using the naming convention: CV_Junior_SURNAME_FIRSTNAME.PDF.
Department of HealthJunior Doctor Research Fellowship – Application form R2 19.04.2016.docwww.health.qld.gov.au
Junior Doctor Research Fellowships Application Form (Round Two)9
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