Vanguard Grant
Application Form
1. Project TitleSimplified Project Title: / (100 characters max) / Research Category:
Scientific Project Title: / (300 characters max) / ClinicalPublic HealthHealth Services
2. Applicant Details
Title: / MsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone: / Mobile:
Email:
Current Appointment: / Current Institution:
I am an Australian or New Zealand Citizen (attached copy of birth certificate or passport to Q15).
I am an Australian Permanent Resident (attached evidence of Permanent Residency or evidence of submission for Australian Permanent Residency to Q15).
I am an Aboriginal or Torres Strait Islander Person.
Other Details: / (Only complete if necessary, 100 characters max)
3. Administering Institution Details
Please ask permission before including other people’s personal information. The Privacy Statement at the end of this document should also be noted
Administering Institution: / Address:
ABN: / Suburb: / State: / Postcode:
Research Office :
Research Office Telephone / Research Office Email:
RAO Main Contact Person:
Title: / MsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone: / RAO Email:
4. Clearance Requirements
This project requires approval from a Human Research Ethics Committee
Other (please specify) (200 characters maximum)
5. Start Date
Nominated date of commencement: / 1st January 20161st April 20161st July 2016
6. Project Synopsis and Potential Outcomes
Using lay terms, describe the overall aims of the research and expected cardiovascular health outcomes. Avoid technical terms. Your answer should be suitable for release to media and general publications.
(1500 characters maximum)
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7. Associate InvestigatorsPlease ask permission before including other people’s personal information. The Privacy Statement at the end of this document should also be noted
A maximum of three associate investigators may be included in the application:
Title: / MsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone: / Mobile:
Email:
Position: / Current Institution:
Role: / (250 characters max)
Title: / MsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone: / Mobile:
Email:
Position: / Current Institution:
Role: / (250 characters max)
Title: / MsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone: / Mobile:
Email:
Position: / Current Institution:
Role: / (250 characters max)
EXECUTIVE SUMMARY
How does the proposed project test the feasibility of an innovative concept in public health, health services or clinical service delivery?
(2000 characters maximum)
9. Outcomes
What outcomes are expected from the project and how might these outcomes lead to improvements in cardiovascular health? Will this study lead to larger, more rigorous studies in the future? If so, how is it proposed to fund these studies?
(2000 characters maximum)
Research Proposal
Please provide a brief summary of your project plan.
(1500 characters maximum)
11. Research Environment
Provide details of facilities, infrastructure and funding that is available to support your proposed research activities.
(1000 characters maximum)
12. Research Plan and Figures
Research plans are limited to three pages (including all tables, all figures, and no more than 15 references) and must be completed using Arial 12 point font with single line spacing. Do not alter page layouts, borders, page or section breaks or any other formatting. Plans must start under this header. All documents not adhering to these guidelines will be reformatted and any additional information exceeding three pages will be automatically deleted. Documents significantly deviating from these guidelines will not be considered further.
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13. Track Record of the ApplicantPlease provide a brief summary of your track record (including publication, presentations, grants and awards) focussing on aspects of your track record, training and skills relevant to the proposed project.
(4000 characters maximum)
14. Heart Foundation Project Funding Budget
Briefly indicate (approximate dollar amounts) how project funding provided by the Heart Foundation will be spent.
Type / Details
(200 characters maximum) / Amount
Personnel (Not applicant)
Equipment
Maintenance
Other
Total
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Evidence of Citizenship
15. Evidence of CitizenshipInsert evidence of citizenship, Permanent Residency or application for Permanent Residency below. Two pages maximum including this page.
Insert here
Signatures
I certify that all details provided in the application (including annexures) are correct and that I have read, understood, and have abided by the instructions associated with this form.
I agree to carry out the project in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007). I acknowledge that all ethics approvals and clearances necessary to complete my project as outlined in this application must be in place before commencement of the work and that the Heart Foundation will not release funds until such time as a copy of all such approvals and clearances have been received by the Heart Foundation Research program.
By signing, I confirm that I have complied with all instructions in the application form and understand that failure to do so may result in the withdrawal of the application from the review process.
I also acknowledge all supporting documentation has been provided with this application. I understand that my application will not be eligible for consideration by the Heart Foundation if this application is incomplete or lacking the required documents.
Please see our Privacy Statement at the end of this document
Applicant (full name) / Date:
Signature / __/__/2015
Head of Department
I certify that appropriate facilities will be available to the applicant if successful and that I am prepared to have the project carried out in accordance with the Australian code for the Responsible Conduct of Research (2007).
Please see our Privacy Statement at the end of this document
Title: / First Name: / Surname:
Email: / Telephone:
Department: / Date:
Signature: / __/__/2015
Verification by Research Office
I, a representative of the Institution’s Research Office, verify that I have checked this application and that to the best of my knowledge, all instructions included in this form have been complied with and all relevant details are correct at the time of lodgement with the Heart Foundation. I acknowledge that the Heart Foundation will not release funds until such time as a copy of necessary ethics approvals and clearances have been received by the Heart Foundation Research program. In addition, I verify that this institution has established administrative procedures for assuring sound scientific practice in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007).
Please see our Privacy Statement at the end of this document
Title: / First Name: / Surname:
Email: / Telephone:
Position:
Institution: / Date:
Signature: / __/__/2015
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Privacy Statement
Your Personal Information is being collected by the Heart Foundation in order to assess your application for this grant. If you are not successful in your application we will retain your application on file indefinitely . We respect your privacy and embrace the principles contained in the Privacy Act. The Heart Foundation (we, us, our) is the National Heart Foundation of Australia and all associated Australian State and Territory Heart Foundation Divisions, full details of which can be found in our Privacy Notice.
If you do not want to receive further communication from us (other than information that relates to this application) or if you have any questions about privacy please contact the Research Program at or call (03) 9321 1581. Our APP privacy policy is set out in our Privacy Notice and details how you may complain about privacy issues and how we would deal with that complaint. It also explains how you can access, correct or update information we hold about you. A copy of our Privacy Notice is available at www.heartfoundation.org.au or on request. [HFPS06-140410-F]
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