senior clinical research fellowship · web viewthe electronic submission will be in adobe acrobat...

Health Research FellowshipRound 4

Application Form

Applications close 5:00 pm AEST 12 June 2013

Applicant’s name:

Proposed location for clinical duties:

Proposed location for research:

Research/clinical area of expertise:

Health and Medical Research

Applicant’s name:

1 Further information

Please read the following documents before completing this form:

Am I Eligible and Frequently Asked Questions

http://www.health.qld.gov.au/ohmr/documents/hrf4-faqs.pdf

Health Research Fellowship Funding Rules - Round Four

http://www.health.qld.gov.au/ohmr/documents/hrf4-funding-rules.pdf

Health Research Fellowships Legal Requirements

http://www.health.qld.gov.au/ohmr/documents/hrf4-legal-req.pdf

2 Application instructions Health Research Fellowship (HRF) round 4 applicants are asked to submit their application using the form provided:

ensure that all sections are completed; sections that are not relevant must not be deleted, record as ‘not applicable’;

using Arial 10.5 point;

single-spaced font; and

2 cm page margins.

Please ensure that the declarations in Section 14 are signed and dated by the recipient and relevant personnel from the Queensland publicly funded health care facility.

The application will be submitted via the Preventive Health Unit, Health and Medical Research (HMR) website (http://www.health.qld.gov.au/ohmr/html/rpu/hrf4_online_app.asp).

The electronic submission will be in Adobe Acrobat Portable Document Format file (.pdf) compatible with version 9 of Adobe Acrobat.

Applicants have the option of submitting the final signed certification page as part of their application (preferred), or as a second separate attachment.

Applications must be submitted by 5.00pm AEST 12 June 2013.

HMR will not accept late submissions.

If applicants are experiencing difficulty submitting applications or certifications online, please contact HMR on +61 7 3405 6121.

Health Research Fellowship Round 4 2 of 21Prepared by Health and Medical Research | May 2023http://www.health.qld.gov.au/ohmr | [email protected] | 3405 6121

http://www.health.qld.gov.au/ohmr/html/rpu/hrf4_online_app.asp

http://www.health.qld.gov.au/ohmr/documents/hrf4-legal-req.pdf


http://www.health.qld.gov.au/ohmr/documents/hrf4-faqs.pdf

3 Personal details

Personal Details

Family name

Given name(s)

Title (Prof., Dr, Mr, Mrs, Ms etc)

Date of birth [DD/MM/YYYY]

Gender Male/Female

Postal address

Postal address

Suburb/town

State

Postcode

Country

Courier address (Line 1)


Suburb/town

State

Postcode

Country

Office phone number

Facsimile number

Mobile phone number

Email address (please ensure that this is correct, as contact will be via email in the first instance)

Secondary email address


Applicant’s name:

Citizenship / resident details

Citizenship

If not an Australian citizen, please indicate if you are a permanent or temporary resident, or hold a Special Category Visa

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 belong to one 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

Academic research qualifications - Copy and paste the tables below as many times as required.

Academic qualification (e.g. BSc., BN, PhD)

Institution

Year

Topic

Clinical qualifications - Copy and paste the tables below as many times as required.


Applicant’s name:

Professional Qualification (e.g. certificate, RCNA, FRACS)

Institution

Year

Professional Memberships - Copy and paste the tables below as many times as required.

Professional Memberships

Institution

Year

Clinical Registrations - Copy and paste the tables below as many times as required.

Clinical registration type (e.g. general)

Professional body and jurisdiction

Registration number

Status (e.g. current)


Applicant’s name:

5 Current Appointments Are you currently funded and employed by the Department of Health or a Queensland publicly funded health facility at least 60% full time equivalent (FTE)?

Yes No

Are you currently undertaking no greater than 20% FTE on clinical or health service research? Yes No

Are you currently undertaking a minimum of 40% FTE on clinical or health service duties? Yes No

If you have answered NO to any of the above questions, you may not be eligible for the Health Research Fellowship.

5.1 Clinical AppointmentsCopy and paste the table below as many times as required for each separate appointment.

Current clinical appointment/s

Job title (e.g. Paediatric fellow, Nurse Unit Manager)

Employee number

Classification including your increment (e.g. HP3.2, MO1.3)

Salary allowances you may receive (e.g. right to private practice)

Date commenced in clinical role [DD/MM/YYYY]

Organisation

Location

Current status of position (e.g. permanent full time/temporary full time/part-time/contract)

Current allocation of clinical time (%FTE)

5.2 Research appointmentsCopy and paste the table below as many times as required for each separate appointment.


Applicant’s name:

Current research activities

Job title (e.g. Research Fellow, Research assistant, PhD Student)

Organisation

Date commenced [DD/MM/YYYY]

Briefly describe (1- 3 sentences) current research activities

Current allocation of research time (%FTE)

5.3 Academic appointmentsCopy and paste the table below as many times as required for each separate appointment.

Current academic/university appointment/s (if applicable)

Job title (e.g. Senior lecturer, head of department)

Duties (e.g. research, administration, student supervision)

Organisation


Duration of appointment [DD/MM/YYYY]

Current status of position (e.g. permanent full time/temporary full time/part-time/contract)

Current allocation of time to university/academic appointment (%FTE)


Applicant’s name:

6 Proposed area of research and location of duties

6.1 Areas 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 (NHMRC).

(http://www.nhmrc.gov.au/grants/policy/keywords.htm).

Area of research

Profession

(e.g Nursing, Allied Health or Medical)

Select only 1 Profession

Broad research area Select only 1 area

Fields 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 your research in lay terms. (This may be used in HMR promotions and/or media releases).

6.2 Research dutiesIn the following section, indicate your proposed allocation of duties (FTE) and location for your research duties if you are awarded a Health Research Fellowship.

Note that the Executive Director of your host Queensland publicly funded health care facility will be required to endorse your proposed allocation of research duties in Section 14.

Ensure the requirements stated in the Funding Rules are considered (i.e. a minimum of 30% of your time is spent on research duties.

Research must be conducted in a Queensland publicly funded health care facility, university or research institute.

Proposed location for research duties

Proposed allocation of research duties (%FTE)

Institute


http://www.nhmrc.gov.au/grants/policy/keywords.htm

Applicant’s name:

Proposed location for research duties

Department

Postal address (Line 1)


Suburb

Postcode

6.3 Clinical dutiesIn the following section, indicate your proposed allocation of clinical duties (FTE) and location for your health service/clinical duties if you are awarded a Health Research Fellowship.

Note that the Executive Director of your host Queensland publicly funded health care facility will be required to endorse your proposed allocation of research duties in Section 14Ensure the requirements stated in the Funding Rules are considered (i.e. a minimum of 30% of your time is spent on clinical duties - which does not include administrative duties).


Applicant’s name:

Proposed Queensland publicly funded health care facility for health service or clinical duties

Proposed allocation of clinical/ health services duties (%FTE)

Queensland publicly funded health care facility

Facility

Department



Suburb

Postcode

6.4 Administrative duties (if applicable)In the following section, indicate your proposed allocation of administrative responsibilities (FTE) and location if you are awarded a Health Research Fellowship.

Involvement may include (but is not limited to):

academic teaching responsibilities;

head of school/ institute/department management and administration;

hospital management and administration; and

Copy and paste the table below as many times as required for each separate appointment.

Proposed administrative duties (if applicable)

Job title (e.g. Senior Lecturer, Head of Department)

Duties (e.g. management, administration, student supervision)

Organisation


Duration of appointment [DD/MM/YYYY]

Proposed allocation of time to administrative duties (%FTE)


Applicant’s name:

7 Selection criteria 1 – track record (40%)

7.1 Clinical and Research ExperienceIn the following sections, outline your track record in health research and clinical practice, focusing on activities that are recent (last five years) and directly related to your application. This will be used to determine your ability or potential to successfully carry out the fellowship.

Clinical experience. Briefly outline your clinical role and summarize your daily clinical duties. Dot points are acceptable (Maximum 1 page).

Research experience. Briefly outline your research experience (Maximum 1 page).

As outlined in the Health Research Fellowship Rules, early career researchers must identify an experienced research mentor.

For the purpose of the Health Research Fellowship, an early career researcher is an applicant who has less than eight years research experience.

Early–career researcher identification

Have you had less than eight years cumulative research experience i.e. do you identify as an early career researcher? Note: early-career researchers are required to identify a research mentor in section 11.

Yes No


Applicant’s name:

7.2 Research collaborations

Outline significant research collaborations, which are relevant to this research proposal. Dot points are acceptable (Maximum 1 page).

7.3 Research funding Outline your most significant research funding grants received.

Copy and paste the rows below, as required.

Name of Funding Body Commencement & Duration

Funding Amount How funds were utilised

[DD/MM/YYYY] to [DD/MM/YYYY]

[$ ]

7.4 Publications List your most significant publications from the last 5 years, which are relevant to this research application and describe, in one to two sentences, the significance of your top 5 publications.

Provide the journal impact factor and number of citations, where possible.

Publications could include:

peer-reviewed research papers;

patents applied for or granted;

reviews, letters, notes;

books or book chapters; and

technical or other reports, inquiries, other journal contributions.

Please do not include conference abstracts.

List your most significant publications relevant to this research application (Maximum 2 pages).

7.5 Key conferences and meetings participationList your most significant participation in key conferences and meetings, which are relevant to this research application.

Participation may include (but is not limited to):

key note addresses;


Applicant’s name:

presentations; and

involvement on scientific organisational committees.

Participation in key conferences and meetings (Maximum 1 page).

7.6 Leadership and trainingBriefly outline your involvement in both research and clinical/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- honour, Masters, PhD, postdoctoral); and

any courses or training that you have undertaken that has directly contributed to your research work.

Research leadership and training (Maximum half page).

7.7 Peer review involvement Please list significant involvement in research peer review. Dot points are acceptable. Involvement may include (but is not limited to):

review of publications; and

review of grant applications.

Peer review involvement (Maximum half page).

7.8 Achievements and awards for research and clinical/health service duties

7.8.1 Research awards


Applicant’s name:

Outline any significant prizes, awards, 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 1 page).

7.8.2 Clinical/health service awards

Outline any significant prizes, awards, honours or peer-recognition you have received for clinical/health services duties relevant to this application. Please include the name and brief details of the award. Dot points are acceptable. (Maximum 1 page).

7.9 Other professional activities and community involvement

Outline your any further significant professional activities and community involvement that is relevant to this research proposal. Dot points are acceptable. (Maximum half page).

8 Selection criteria 2 – research plan (40%)

This section will provide the details of your research plan to the HRF review panel.

Ensure that all sections are completed, sections that are not relevant must not be deleted, record as ‘not applicable’.

Title of research plan (maximum 100 words).

Location of research duties (maximum 100 words).

Brief background: In this section, include the current knowledge in your proposed field of research and highlight any gaps in the knowledge (Maximum 1 page).


Applicant’s name:

Aims and rationale of research (Maximum 5 sentences).

Research hypothesis (Maximum 5 sentences).

Brief methodology: In this section include relevant technologies, statistical and analytical methods (Maximum 1 page).

Key team members: In this section include all key team members and collaborators. Outline briefly the benefit of the collaborators to your team. (Maximum half page).

Details of other sources of support for the research plan (Maximum half page).

Expected outcomes from research and plans for dissemination within Queensland public health system (Maximum half page).

Plans for your research career sustainability, including long term goals (Maximum half pages).

8.1 Research milestonesIn the section below describe the proposed scientific milestones for each year of the fellowship.

Ensure that the milestones are focused to achieve the desired outcomes.

If the application is successful, the completion of milestones will be addressed in the yearly progress report.

Do not include:

writing grant applications;

applying for and obtaining ethics applications;

recruitment of staff;

attendance at conferences or symposia; and


Applicant’s name:

writing publications.

Milestones: Briefly outline the proposed milestones for each year of the fellowship.

Year 1

Year 2

Year 3

Plans for sustaining the research project beyond the terms of the Fellowship (Maximum half pages).

9 Selection criteria 3 – proposed clinical/health service duties (10%)

Describe the proposed clinical or health service duties to be undertaken and how they relate to the proposed project (Maximum half page).

10 Selection criteria 4 – vision for Queensland and benefit to applicant (10%)

10.1 Vision for QueenslandDescribe your vision for Queensland. This may include (but is not limited to) the means by which the award of the Fellowship will:

augment the current research conducted at the host Queensland publicly funded health care facility;

benefit the institution, local, State and International health care;

increase research capacity in Queensland’s publicly funded health care facilities, through training, leadership, team building and collaboration; and

lead to improved patient outcomes through innovation or the implementation of or change to guidelines or policies.

Vision for Queensland (Maximum 1 page).


Applicant’s name:

10.2 Benefit to applicant

Benefit to applicant – Clinical Duties: Describe how your current clinical activities will change if you are a Fellowship recipient and how the fellowship will develop your career (Maximum half page).

Describe how you propose that your clinical/health service duties will be back-filled in your Queensland publicly funded health care facility (Maximum 5 sentences).

Benefit to Applicant- Research Career: Describe how your current research activities will change if you are a Fellowship recipient (Maximum 0.5 page).

11 Identification of research mentor (if applicable)Have you identified a research mentor? Yes No

If yes, please fill in details below.

Research Mentor


First name, last name

Research field

Academic qualifications

Clinical qualifications

Institute

Office phone number

Mobile phone number

Email address

Relationship to applicant

Permission to contact


Applicant’s name:

12 External assessorsHMR reserves the right to appoint external assessors. These external assessors may be provided with relevant documentation to complete the assessment by HMR.

List a maximum of three name(s) below, of any people to be excluded from the assessment process where relevant (i.e. conflict of interest).

Excluded external assessors (if relevant).

13 RefereesApplicants will contact and seek agreement from two referees who have agreed to comment on their Health Research Fellowship application. Include their contact details and also their relationship to the applicant (for example ‘current manager’). It is preferred applicants provide referees that currently work closely with the applicant. If possible provide one clinical and one research.

Referee 1


Given name(s), last name

Postal address Line 1


Suburb/town

State

Postcode

Country



Suburb/town

State

Postcode

Country


Applicant’s name:

Office phone number

Facsimile number

Mobile phone number

Email address



Referee 2


Given name(s), last name



Suburb/town

State

Postcode

Country



Suburb/town

State

Postcode

Country

Office phone number

Facsimile number

Mobile phone number

Email address



Applicant’s name:


14 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

“HRFR4_CERT_ [Applicant’s Surname].pdf, by email: [email protected]

or via facsimile to +61 (0)7 3405 6131.

14.1 Applicant’s certificationI, the applicant, certify that all details given in this application are correct

Applicant’s certification

Title Applicant's details

Family name Applicant's details

First name(s) Applicant's details

Signature

Date [DD/MM/YYYY]

14.2 Research Mentor certification (if applicable)I, agree to act as a research mentor for applicant's name, should the applicant be awarded a Health Research Fellowship.

Research mentor certification

Title Research Mentor's details

Family name Research Mentor's details

First name(s) Research Mentor's details

Signature

Date [DD/MM/YYYY]

14.3 Queensland publicly funded health care facility’s certification


mailto:[email protected]

Applicant’s name:

Proposed allocation of research and clinical/ health services duties

Proposed allocation of research time (%FTE)

Applicant to provide details from section 6

Proposed institute Applicant to provide details from section 6

Proposed allocation of clinical/ health services duties (%FTE)


Queensland publicly funded health care facility


Department Applicant to provide details from section 6

I give this applicant my full support in their application for a Health Research Fellowship Round Four. If successful, this applicant will be provided with the necessary facilities to carry out the research project as well as the time as specified:

I am aware that, if successful, the Queensland publicly funded health care facility will need to back-fill the applicant’s position for the required time.

Advice for back-filing the clinical position can be found in Section 12.1 of the Health Research Fellowship Funding Rules (http://www.health.qld.gov.au/ohmr/documents/hrf4-funding-rules.pdf)

Host Queensland publicly funded health care facility’s certification

Title Hospital/Health facility Executive Director's details

First name (s) Hospital/Health facility Executive Director's details

Family name Hospital/Health facility Executive Director's details

Signature of Executive Director

Position Hospital/Health facility Executive Director's details

Queensland publicly funded health care facility Hospital/Health facility Executive Director's details

Date [DD/MM/YYYY]



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