After Completion This Form Should Be Returned To

Personal Resarch Awards

2016

APPLICATION FORM

After completion this form should be returned to:

Pharmacy Research UK

66-68 East Smithfield

London E1W 1AW

CHECKLIST

I confirm that I, the lead applicant:

☐Am a member of the Royal Pharmaceutical Society. My membership number is …………………………….

☐Have completed all sections of this Application Form

☐Have included brief CVs (my own and all supervisors listed in my application)

☐Have obtained all necessary supporting signatures in Section 7 (Declarations)

☐Have included a cover letter

☐Have included two hard copies of the application form

☐Have emailed this Application Form and any supplementary documents to:

Personal Research Award

Pharmacy Research UK
66-68 East Smithfield

London E1W 1AW

SECTION 1: PERSONAL DETAILS

Name / Title / First name / Last name
Home Address
Postcode
Telephone No.
Mobile No.
Email
GPhC Reg No. /

Date of registration:

If you are not currently registered, are you undertaking pre-registration training? Yes ☐ No☐

Please indicate which award you are applying for (by placing an ‘x’ in the appropriate box below).
Galen Award / ☐ /
Leverhulme Pharmacy Research Fellowship / ☐ /
Both of the above awards / ☐ /
Where did you hear about this research funding?

SECTION 2: CURRENT EMPLOYMENT DETAILS

Post Held
Organisation
Address (of branch if applicable)
Postcode
Work Tel. No.
Email
Current Salary / £
Please provide a brief outline of your responsibilities– Max 250 words
How do you plan to balance your current work activities with your proposed research project and training?(Max 500 words)

SECTION 3: DETAILS OF PROPOSED PROJECT

Full title of project
Proposed duration (months) / Proposed start date / Total cost
£
Have any other applications for research funding been made for this project? (Please place ‘x’ in the appropriate box) / Yes ☐ No☐
Will ethical approval required for this project? (Please place ‘x’ in the appropriate box) / Yes ☐ No ☐ Already obtained ☐
If no, please justify:

Aims and objectives

Background

Plan of investigation

Project timetable

List of outputs/deliverables and plans for dissemination

Risk management

SECTION 4: DEVELOPING RESARCH CAPACITY AND CAPABILITY IN PHARMACY

Development of Research Skills(Max 500 Words)

How will the award contribute to your professional development? (Max 500 words)

How will the proposed study contribute to pharmacy practice? (Max 500 words)

SECTION 5: SOURCES OF ADVICE AND SUPERVISIONS

Please provide details of the person(s) consulted for the elements listed below (if any) when completing this application. Please also indicate if any of the advisers have seen your completed application form.
Study Design
Name
Email
Telephone
Statistics
Name
Email
Telephone
Budgeting /Finance
Name
Email
Telephone
Ongoing support and supervision
Please provide the details of the person(s), experienced in research, who will supervise this project. Please provide two hard copies and one electronic copy of each supervisors’ Curriculum Vitae.
FIRST SUPERVISOR
Name / Title / First name / Last name
Address
Postcode
Telephone No.
Email
Position
Research Experience
Please indicate the supervisors’ role and expertise in relation to the proposed project, time commitment and number of students currently supervised and at what level, i.e. MSc/PhD.
SECOND SUPERVISOR (if applicable)
Name / Title / First name / Last name
Address
Postcode
Telephone No.
Email
Position
Research Experience

Please indicate the supervisors’ role and expertise in relation to the proposed project, time commitment and number of students currently supervised and at what level, i.e. MSc/PhD.

THIRD SUPERVISOR (if applicable)
Name / Title / First name / Last name
Address
Postcode
Telephone No.
Mobile No.
Email
Position
Research Experience

Please indicate the supervisors’ role and expertise in relation to the proposed project, time commitment and number of students currently supervised and at what level, i.e. MSc/PhD.

SECTION 6: FINANCE

Category / Details, if appropriate / Cost
Staff costs [e.g. salary, locum cover, etc.]
Travel and subsistence
Project costs [e.g. meetings, training programme, attendance, postage, printing, publications, conference attendance, etc.]
Formal and informal training and support costs not included elsewhere
Other (please provide details)

SECTIONS 7: DECLARATIONS

FOR APPLICANT ONLY:
I wish to apply for a Personal Resarch Award for the year 2016 on the basis of the information given in this appication.
I declare that I will be actively engaged in, and in day to day control of the project.
I agree that Pharmacy Research UK may hold and process, by computer, or otherwise, personal and other data contained within this application and, if successful, additional data requested.
Signature / Date / Name (BLOCK CAPITALS)
FOR THE HEAD OF DEPARTMENT OR ORGANISATION:
I declare that I have read this application and that, if funded, the work will be accommodated and administered in the department / organisation and that the applicants for whom we are responsible may undertake this work.
Signature / Date / Name (BLOCK CAPITALS)
Post Held
Organisation
Address
Postcode
Tel. No.
Email
FOR THE ADMINISTERING ORGANISATION’S FINANCE DEPARTMENT, to be signed by finance officer or equivalent:
I declare that the financial information given on this form is complete and correct and agree to administer the award, if made. The staff grades and salaries quoted are correct and in accordance with the normal practice of this organisation.
Signature / Date / Name (BLOCK CAPITALS)
Post Held
Organisation
Address
Postcode
Tel. No.
Email

Please return two hard copies and one electronic copy of this form and relevant supporting documents to:

Personal Research Awards

Pharmacy Research UK

Royal Pharmaceutical Society

66-68 East Smithfield Street

London E1W 1AW

Tel: 02075722455

Email:

By 5pm on Wednesday 4th May 2016.

Please ensure this form is fully signed before submitting

Please note: Late or incomplete applications will not be accepted