metrosouth.health.qld.gov.au · Web viewAuthor: Paul Dall'Alba : Created Date: 07/12/2016 16:36:00 : Title: Metro South Health | Report Cover Page template : Subject: Template for

Centres for Health Research

Research Support Scheme2017 Application Form for:

New Appointment Grants

Sponsored by:

CLOSING DATE: 5:00 PM MONDAY 8 AUGUST 2016

The NEW APPOINTMENT GRANT ($75,000 p.a. for 2 years) is provided to assist a new Metro South Health (MSH) clinical appointee establish their research program. The application must be submitted within 18 months of the official start date of employment.

APPLICATION INSTRUCTIONS

Refer to the 2017 Funding Guidelines when preparing your application.

Press <Tab> to move between fields.

All sections of the form must be completed.

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 PA Research Support Scheme should be directed to:PAH Research Grant Administration Officer Email: [email protected]

PA RESEARCH SUPPORT SCHEME2017 NEW APPOINTMENT APPLICATION

PROJECT TITLE(Maximum 200 characters including spaces)

APPOINTMENT START DATEThis must be within the 18 months leading up to the application submission deadline

Date commenced/proposed date of commencement (d/mm/yy):

mailto:[email protected]

INVESTIGATIVE TEAMThe Applicant must be the PI (Principal Investigator)

The maximum number of: Co-Investigators (CIs) = 4; Associate Investigators (AIs) = 2

Title Name Health profession

Organisation

PI Click to choose First name Surname Click to choose Click to choose

CI1 Click to choose First name Surname Click to choose Click to choose




AI1 Click to choose First name Surname Click to choose Type name here

AI2 Click to choose First name Surname Click to choose Type name here

FUNDING BODYThe New Appointment Grant is funded by SERTA

ACKNOWLEDGEMENT OF SERTA GRANT PAYMENT CONDITIONSI, [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:

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APPLICANT ELIGIBILITY CHECKLIST

To be eligible for a 2017 New Appointment Grant the Applicant must be able to answer:Yes to questions 1-4

No to question 6

Yes No

1 Are you a member of staff of (or form a formal appointment with) MSH?

2 Are you engaged in clinical or health service duties?

3 Will your appointment be at least 0.5 FTE for the duration of the grant?

4 Is the official start date for the appointment within the last 18 months?

5 Will the majority (more than 50%) of the research activity take place at the PAH campus?

6 Is the proposed research activity currently funded through an award type currently listed on the Australian Competitive Grants Register or international equivalent?

MANDATORY QUESTIONSAPPLICANT APPOINTMENT FRACTION AND LOCATION

Fraction MSH appointment (e.g. 0.6) FTE

MSH appointment location PA Hospital

Beaudesert Hospital

Logan Hospital

QEII Jubilee Hospital

Redland Hospital

Community Centre

Maternity Services

Oral Health Services

Addiction and Mental Health

APPLICANT APPOINTMENT DETAILSProvide details of your 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

NOTE: N/A (or similar) will not be accepted

LOCATION 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 PAH 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 site specific approval (SSA) number(s)

SSA SSA/ /QPAH/ SSA SSA/ /QPAH/ SSA SSA/ /QPAH/

NOTE:

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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

ELIGIBILITY CERTIFICATIONI, [First Name, Surname], certify that I:

Meet the relevant eligibility criteria for the PA Research Support Scheme.

Have answered all mandatory questions.


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1. PRINCIPAL INVESTIGATOR (APPLICANT) CONTACT DETAILS

Applicant name Click to choose First Name Surname

Position

Organisational department Department name

Phone number(s) 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

PARTICIPATIONSummarise your participation in the broad research plan proposed in this application (maximum 300 characters including spaces)

RESEARCH TIME

Expected 2017 time allocation to: This study (hr/wk): Other studies (hr/wk):

Do you expect to have an extended period of absence during 2017?

Yes No

If Yes, provide expected dates DD/MM/YEAR - DD/MM/YEAR

Reason(300 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.

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GRANTSProvide details of 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]

[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

PEER REVIEW INVOLVEMENTList your involvement in peer review. Involvement may include (but is not limited to) committees, grant review, review of publications

Press <Enter> after each entry to maintain list formatting

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CO-INVESTIGATOR 1CI1 CONTACT DETAILS

CI1 name Click to choose First Name Surname

Position

MSH site Click to choose


Phone number

Email address

CI1 ACADEMIC QUALIFICATIONS

Qualification Institution Date

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

CI1 PARTICIPATIONSummarise the role of CI1 in the broad research plan proposed in this application (maximum 300 characters including spaces)

CI1 RESEARCH TIME


Does CI1 expect to have an extended period of absence during 2017?

Yes No



CI1 PUBLICATIONSList publications produced in the last 5 years with ALL authors provided



1.

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Position



Phone number

Email address



DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR


CI2 RESEARCH TIME



Yes No






1.

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Position



Phone number

Email address



DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR


CI3 RESEARCH TIME



Yes No






1.

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Position



Phone number

Email address



DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR

DD/MM/YEAR


CI4 RESEARCH TIME



Yes No






1.

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ASSOCIATE INVESTIGATORSASSOCIATE INVESTIGATOR 1Outline the role of AI1 in the broad research plan proposed in this application and indicate why AI1 has been included within the research team (maximum 1,000 characters including spaces)

ASSOCIATE INVESTIGATOR 2Outline the role of AI2 in the broad research plan proposed in this application and indicate why AI2 has been included within the research team (maximum 1,000 characters including spaces)

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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 Research Proposal here

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BUDGET

Item Description Amount

Personnel/Salaries $

Maintenance(consumable items to be purchased)

$

Equipment $

Other(NOTE: computers will not be funded)

$

Total $

Budget justification (maximum 1,000 characters including spaces)

OTHER SUBMITTED GRANT APPLICATIONSProvide details of grant applications related to this study submitted to other funding bodies in the current year

Funding body and type Project title Budget

$

$

$

$

$

$

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REVIEWER NOMINATIONS

Applicants must nominated three reviewers for this applicationFor nominations to be eligible the Applicant must be able to answer Yes to all questions

Yes 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 PRINCIPAL INVESTIGATORI, [First Name, Surname], certify that written agreement (such as an email) has been obtained from all investigators named in this Research Support application and that all details provided are correct.

I understand that should this application be successful, all named Co-Investigators on this application will be required to sign the Acceptance of Offer.

On behalf of the investigative 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.

I certify that research will not commence until all ethical clearances and site specific approvals (SSAs), if required, have been obtained


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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:__________________________________________________________


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Documents

metrosouth.health.qld.gov.au · Web viewAuthor: Paul Dall'Alba : Created Date: 07/12/2016 16:36:00 : Title: Metro South Health | Report Cover Page template : Subject: Template for