(A)A Clinical Lectureship for Nurses and Allied Health Professionals

Please refer to the Joint SA/Health and Care Research Wales Guidance for Applicants and Conditions of Award before completing this Application Form / For Office Use Only

Which type of Lectureship do you wish to apply for? Please tick the appropriate box.

(a)A Clinical Lectureship for Nurses and Allied Health Professionals

(b)A Senior Clinical Lectureship for Nurses and Allied Health Professionals

(c)A Clinical Lectureship for Medical Professionals

(d)A Senior Clinical Lectureship for Medical Professionals

(e)A Non-Clinical Lectureship

(f)A Senior Non-Clinical Lectureship

(g)A Reader Award (Clinical)

(h)A Reader Award (Non-Clinical)

Please note:

If you are clinically qualified and still spending some of your time in clinical training and/or practice, you should apply for a Clinical Lectureship, Senior Clinical Lectureship or Reader (Clinical).
If you are clinically qualified but have left, or wish to leave clinical practice, you should apply for a Non-Clinical Lectureship, Senior Non-Clinical Lectureship or Reader (Non-Clinical).
Non-clinically qualified researchers are also welcome to apply for the Non-Clinical Lectureship, Senior Non-Clinical Lectureship or Reader awards.

Details of theCandidate

Surname / Forename(s) / Title / Position

Address (including email)
Telephone

Qualifications, Training, Registration and Experience of Candidate

PLEASE NOTE: Applicants should complete only the relevant sections for the type of Lectureship they are applying for. Please refer to the Guidance for Applicants document.

(a)Qualifications and Training Level of Candidates applying for a Clinical Lectureship

(I) For Nurses, Allied Health and Medical Professionals:

Please outline if you currently hold, or have recently submitted a thesis for a PhD/MD/Prof Doc or equivalent qualification.This is mandatory to meet the eligibility criteria for application for a Clinical Lectureship.

YesNo

Please give details of date of submission of thesis or final award date where applicable:

(II) For Nurses and Allied Health Professionals Only:

Please outline if you have current registration with the Nursing and Midwifery Council (NMC), the Health Care Professionals Council (HCPC) and/or other relevant professional body? This is mandatory to meet the eligibility criteria for application for a Clinical Lectureship.

YesNo

Please give details of your current registration and any registration plans between now and the award date of March 2016:

(III) For Medical Professionals Only:

Please confirm that you are currently eligible for this award at training level ST4 or above?

YesNo

If no, please state if and when you expect to reach this level (it is mandatory for this to take place prior to March 2016 in order to be eligible for this award)

(b)Qualifications and Training Level of Candidates applying for a Senior Clinical Lectureship or Reader (Clinical)

(I) For Nurses, Allied Health and Medical Professionals:

To apply for this award, you must hold a PhD/MD/Prof Doc or equivalent qualification. Please confirm you have obtained such a qualification and provide details and dates in the text box below.

YesNo

Please give brief details and date of qualification.

(II) For Nurses and Allied Health Professionals Only:

YesNo

Please give details of your current registration and any potential changes to this before March 2016:

(III) For Medical Professionals Only:

Has the candidate completed clinical training? Y/N / Specialty Area of CCT / Date of CCT, or due date of CCT

(c)Qualifications and Experience of Candidates applying for a Non-Clinical Lectureship, Senior Non-Clinical Lectureship or Reader Award

Does the candidate hold a clinical qualification relevant to stroke? Y/N / Details of qualification and date on which clinical training was completed / Reason for leaving clinical practice (where applicable)

Please outline if you currently hold a PhD? This is mandatory to meet the eligibility criteria for application for Non-Clinical Lectureship/Senior Lectureship/Reader Awards.

YesNo

Please give brief details of PhD and award date:

Please outline the number of years of post-doctoral research experience you have to date, and give a brief summary of your current or most recent research position and its relevance to stroke research:

Current and Previous Support of Candidate

(a) Is your position currently being supported by another funding body as a fellowship, lectureship or similar post?

YesNo

If yes, please give details of the funding award including the start and end dates:

(b) Have you held a previous fellowship, lectureship or similar post?

YesNo

If yes, please give details of the previous funding award including the start and end dates:

Details of the Head of DepartmentNominating the Candidate at Host Higher Education Institute (HEI)

Surname / Forename(s) / Title / Position

Address
Telephone
Email

Details of the Director, Vice-Chancellor, Principal or Dean at the Host HEI

Surname / Forename(s) / Title / Position

Address
Telephone
Email

Details of the currentStrategy of the HEI, and in particular, its relevance to strokeresearch where applicable(This statement should not exceed one side in length)

Details of the current status and future plans of the HEI in supporting or capacity building in stroke research and/or related relevant disciplines (This statement should not exceed one side in length)

Details of the NHS/Clinical Employer (Do Not Complete this Section if applying for a Non-Clinical Lectureship, Senior Lectureship or Reader Award)

Surname / Forename(s) / Title / Position

Address
Telephone
Email

Address of the HEI Department where candidate’s research will be hosted

Address
Telephone

Research Programme Title

Abstract of Research (200 words max)

Lay Research Programme Title

Lay Abstract of Research (300 words max)

Summary of requested support from the Stroke Association/Health and Care Research Wales

Proposed Start Date:

Year 1 (£) / Year 2 (£) / Year 3 (£) / Year 4 (£) / Year 5 (£) / Total
Salary (Yours)
Equipment
Consumables
Salaries of Other Research Staff
Travel
Other expenses
Stroke Association Support Programme / £4,500 / £4,500 / £4,500 / £4,500 / £4,500 / £4,500
Total Support Requested

Support from elsewhere

Is your related research currently being supported by another funding body?

YesNo

If yes, please give details:

Parallel submission

Are you currently applying for a fellowship, lectureship or other similar position elsewhere?

YesNo

If yes, please give details:

Intellectual Property

Could the research in this application lead to the generation of a new product/process, or the generation of intellectual property?

YesNo

If yes, have you consulted your in-house technology transfer or IP liaison unit?

YesNo

Please give details:

Have you involved a Research Design Service or Clinical Trials Unit in the design of the research application?

YesNo

If yes, please give details:

Public and/or Patient Benefit and Involvement
Please describe how the public and/or patients have been involved in the research to date and the development of this application:

Please describe how the public and/or patients will be involved in this work:

Please describe how the proposed research will have benefit for the public and/or patients affected by stroke:

Please describe how you will disseminate the outcomes of the research to the public and/or patients:

Previous Awards from the Stroke Association

Please list any previous funding from the Stroke Association that the host HEI has received within the past five years:

Please list any previous funding from the Stroke Association that the candidate has received within the past five years:

Letter of Support from HEI

Has a letter of support been provided and attached to this application confirming that the relevant support is in place for this candidate to take up a lectureship/senior lectureship/reader position,and signed by the Head of Department and the Director, Vice-Chancellor, Principal or Dean of the HEI?

YesNo

Please note:

This is mandatory for all application submissions.Please see the Guidance for Applicants for required details that the HEI support letter should include.

Letter of Support from NHS/Clinical Employer (for Clinical Lectureships, Senior Clinical Lectureship and Reader (Clinical) applications only)

Has a letter of support been provided and attached to this application confirming that the relevant support is in place for this candidate to take up a lectureship/reader position, and signed by the NHS employer?

YesNo

Please note:

This is mandatory for a Clinical application submission. Please see the Guidance for Applicants documentfor required details that the NHS support letter should include.

Declarations and Signatures (Please provide wet signatures on the original hard copy application form. Electronic signatures will not be accepted).

Signature of Lectureship/Reader Candidate

Acceptance of Conditions of Award:

“I have read the Conditions of Award, and if this application is successful, I agree to abide by them. I have no obligations which would conflict with the Conditions of Award.”

Signed: Date:

Signature of Director, Vice-Chancellor, Principal or Dean of the HEI

Acceptance of Conditions of Award:

“I confirm I have read this application, and that if it is granted, the research will be accommodated and administered in accordance with the Conditions of Award. I agree to the statements in sections 27 and 28 and will ensure the Lecturer/Reader receives all the necessary support to undertake this position. Staff grading and salary are at an agreed level that will be guaranteed throughout the Lectureship/Reader Award. I have no obligations which would conflict with the Conditions of Award.”

Signed: Date:

Printed Name, Initials and Position of the above:

Signature of the Head of Department and the Finance or Research Administration Officer at HEI

The Head of Departmentand the Finance or Research Administration Officer should sign the following declaration:

Signature of Head of Department: / Signature of Finance or Research Administration Officer:
Printed Name, Initials and Position of above: / Printed Name, Initials and Position of above:
Address (if different from Award Holder): / Address:

Signature of Research Sponsor

The NHS Research Governance Framework for Health and Social Care requires that all work covered by this proposal must be sponsored. The Stroke Association is unable to act as sponsor for the work it funds.

“I accept the responsibilities of research sponsor as defined by NHS Research Governance Framework for Health and Social Care for the research outlined in this award application.”

Signature of Sponsor: / Printed Name and Initials of Sponsor:
Address: / Position:
Organisation:
Tel: / Date:
Signature of NHS/Clinical Employer
(Applications for Clinical Lectureships, Senior Clinical Lectureships and Reader (Clinical) only)

Acceptance of Conditions of Award:

“I have read the Conditions of Award, and if this application is successful, I agree to abide by them. I agree to the statement in section 29 stating the clinical hours and the maximum on call/emergency hours that the candidate will commit to, and commit to ensure that this will not be exceeded during the course of this Lectureship/Reader Award. Staff grading and salary are at an agreed level that will be guaranteed throughout the Lectureship/Reader Award.I have no obligations which would conflict with the Conditions of Award.”

Signed: Date:

Printed Name, Initials and Position of the above:

Address:

Proposed Research Programme by Candidate

Please refer to the Guidance for Applicants. The statement should not exceed 6 pages. One additional page (the seventh) may be used for references only, 9 sides of A4 are permitted including additional figures, tables and a timeline or Gantt chart, see Guidance for Applicants for more details on this.Please include details of the potential role of PhD/Post-Doc researchers or other research training positions that will be incorporated into this research plan.

Plans for Building a Research Team and Attracting Further Fundingby Candidate (This statement should not exceed one side in length)

Support provided by the HEI for the Candidate to apply for training and research posts and attract further funding (This statement should not exceed one side in length, you may refer to the Support Letter, but where additional information is provided/necessary please include it here).

Statement of support and infrastructure provided by the HEI for the Lecturer/Reader to take up this post (laboratory/office space, equipment, administration support and any extra training or mentoring provided (This statement should not exceed one side in length, you may refer to the Support Letter, but where additional information is provided/necessary please include it here).

This section is for Applications for a Clinical Lectureship, Senior Clinical Lectureship or Reader (Clinical) only.

Statement by the NHS employer of support for this candidate to spend time in academic research. The agreed clinical hours and agreed maximum on call/emergency hours that the candidate will commit to should be outlined in brief as in the attached support letter. (This statement should not exceed one side in length, you may refer to the Support Letter, but where additional information is provided/necessary please include it here).

Research Purpose (N.B. This information is for Stroke Association Research Office use only and will not be used to judge your application)

Please select ONE of the following that most appropriately fits the purpose of the research in this application:

Prevention / Acute Stroke Service / Long Term or Community Care
Rehabilitation / Applied Neuroscience

Type of Research

Please select ONE of the following that most appropriately fits the purpose of the research in this application:

Patients and Carers / Clinical Pharmacology / Clinical Psychology
Epidemiology / Genetics, Ethnic factors / Imaging
Information, Education / Neuropathology / Neuroprotection
Neurorehabilitation / Primary Care / Quality of Life
Stroke Unit Care / Surgical Treatment / Vascular Pathology

Research Keywords

Please provide five keywords to describe more specifically the research in this application:

1. / 2.
3. / 4.
5.

Details of Support Requested

Please refer to the Guidance for Applicants and Conditions of Awardto help fill this table. Salary increments, as outlined on the NHS Clinical pay scale for Clinical Lectureship or Reader applicants, or the HEI pay scale for Non-clinical Lectureship or Reader applicants, should be included.

Salary Cost of Lecturer/Reader Candidate

Salary Grade/
NHS Spine Point / Inclusive Salary Costs Requested from the Stroke Association / Inclusive Salary Costs from the HEI/NHS Employer
Year 1 (£) / Year 2 (£) / Year 3 (£) / Year 4 (£) / Year 5 (£) / Year 1 (£) / Year 2 (£) / Year 3 (£) / Year 4 (£) / Year 5 (£)
Total Salary (£)
Percentage of salary (%) requested from the Stroke Association
Total Salary Costs (£) / (A)Total requested from the Stroke Association/Health and Care Research Wales / (B)Total salary support from the HEI/NHS Employer
TOTAL / Total Overall Salary (A +B) (£)

Research Expenses

A maximum request of £35,000 for 5 year awards, or £28,000 for 4 year awards,is permitted with this application, provided the combined overall cost of salary, expenses and support costs of £4,500 per year (see summary table below) is within the maximum amounts specified for the award type (see Guidance for Applicants). If the Stroke Association’s contribution to salary is less than 50%, applicants may apply for more research expenses up to the cost of 50% of their salary.

Year 1 (£) / Year 2 (£) / Year 3 (£) / Year 4 (£) / Year 5 (£)
Materials / Consumables
Equipment
Salaries of Other Staff
Travel
Other expenses
Total (£)

Summary of total support requested from the Stroke Associationand Health and Care Research Wales

Please provide calculated total costs requested from the Stroke Association and Health and Care Research Wales. Please refer to the Guidance for Applicants for the maximum amount you may request for each Lectureship/Reader type.

PLEASE NOTE:Applications exceeding the maximum permitted total cost will be automatically rejected.

Year 1 (£) / Year 2 (£) / Year 3 (£) / Year 4 (£) / Year 5 (£) / Total
Salary
Equipment
Consumables
Salaries of Other Staff
Travel
Other expenses
Stroke Association Support Programme / £4,500 / £4,500 / £4,500 / £4,500 / £4,500 / £4,500
Total Support Requested

N.B: This summary table will need to be copied exactly to section 15 of the form. Please ensure your calculations are correct, the Stroke Association/Health and Care Research Wales will not be able to award further funds under any circumstances and will not be responsible for correcting any errors in these calculations.

Please provide a detailed justification of the expenses requested above (up to 400 words):

NHS Support Costs and NHS Treatment Costs

Please only fill in this part of the form if relevant to your application – please refer to the Guidance for Applicants document first.

If you need to complete this section, please refer to section 6 of the Conditions of Awardand the Guidance for Applicants. All costs must conform to the AcoRD guidelines.

NHS Support Costs (Please specify) / Year 1 (£) / Year 2 (£) / Year 3 (£) / Year 4 (£) / Year 5 (£) / Total (£)
Total (£)
NHS Treatment Costs (Please specify)
Total (£)

NHS Service Support Costs