/ STELLENBOSCH UNIVERSITY
FACULTY OF MEDICINE AND HEALTH SCIENCES /

SCIENTIFIC TRAVEL & PUBLICATION INCENTIVE FUND
SCIENTIFIC TRAVEL: CONFERENCE APPLICATION FORM (STC-2017-06)

(a)Before this form is filled in, the regulations of the SCIENTIFIC TRAVEL AND PUBLICATION INCENTIVE FUNDshould first be read.

(b)This application should be completed ELECTRONICALLY.

(c)The following supporting documents or copies of these documents should be attached to the application as correspondingly marked appendices:

Appendix A:The official announcement, advertisement or invitation of the meeting.

Appendix B:The programme of the meeting. (If the programme is not yet available, this should be mentioned in Appendix B and the programme should immediately be forwarded to the relevant official after receipt.)

Appendix C:Written proof of the registration fees required (not proof of payment).

Appendix D:A summary of approximately half an A4 page of the congress contribution(s) (eg. abstract)andproof of acceptance of the contribution.(If the proof of acceptance is not yet available, this should be indicated on the checklist and should immediately be submitted upon receipt, but do not neglect to submit your application by the deadline date.)

Appendix E:A numbered list of all papers, with complete references, of the previous
3 years(i) at international professional conferences, (ii) at national professional conferences and (iii) at other meetings (but not popular meetings). The cases for which financial support from SU has been obtained should be indicated with an asterisk beside the numbers. If no papers have been presented, this should also be indicated.

Appendix F:A numbered list of all publications, with complete references, of the previous 3 yearsin the category of (i) journal articles, (ii) the published proceedings of professional congresses, (iii) specialist books, (iv) chapters in books, (v) research reports and (vi) others (not popular). If no documents have been published, this should also be indicated.

Appendix G:A written quotation from an approved travel agency in respect of the cheapest air-travel tariff. Such quotation should apply to the ACTUAL number of days of THe MEETING (even if additional travelling/visits are undertaken with financing from other sources).

Appendix H:The officialSU itineraryform, completed correctly–Appendix H(optional for this application, but required by Finances prior to claiming funds).

(d)There are three calls during the year, closing 1 March, 1 July, and 1 Novemberannually for dedicated travel periods each, provided a call is officially announced.

(e)ALL levels of staff, with the exception of Executive Heads of Department, are required to obtain a written recommendation from their divisional/departmental head prior to submitting their application to the Research Development and Support Division (Tygerberg campus). In the case of postgraduate students a recommendation from the supervisor will suffice.

APPLICATIONS SHOULD BE SUBMITTED BEFORE A CONFERENCE TAKES PLACE, EVEN WITHOUT PROOF OF ABSTRACT ACCEPTANCE. NO EX POST FACTO APPLICATIONS ARE CONSIDERED.

IN THE EVENT OF A SUCCESSFUL APPLICATION, NOTE THAT CLAIMS AGAINST YOUR ALLOCATED FUNDING NEED TO BE PROCESSED WITHIN 90 DAYS OF YOUR RETURN FROM THE SCIENTIFIC VISIT.

Completed application forms must be sent electronically and in hard copy to Tashwell de Wet () Research Development and Support Division (RDSD), Room 5009A, 5th Floor, Education Building, Faculty of Medicine and Health Sciences, Tygerberg campus.

Enquiries: Tashwell de Wet (021 938 9056); )

/ STELLENBOSCH UNIVERSITY
FACULTY OF MEDICINE AND HEALTH SCIENCES /

SCIENTIFIC TRAVEL & PUBLICATION INCENTIVE FUND
SCIENTIFIC TRAVEL: CONFERENCE APPLICATION FORM (STC-2017-06)

CHECKLIST:
National or international conference application

NAME: ………………………………………………………………………….…….

REQUIREMENTS / YES / NO / IF NO, PLEASE CLARIFY
The OFFICIAL announcement, advert
or invitation to the meeting
The programme to the meeting with your name highlighted if applicable
(if available at this time)
Written proof of registration fees required
Abstract (half A4 page summary) as submitted to the conference organising committee
Proof of acceptance of abstract (IMPORTANT: Acceptance of abstract does not need to be submitted with this application if not yet available, but would be required as soon as it becomes available, prior to the conference)
A numbered list of all conference papers with complete references of the previous 3 years
A numbered list of all publications with complete references of the previous 3 years
A written air travel quotation from an official SU travel agency
FOR OFFICE
USE ONLY /
Previous support 2017 / YES / NO / APPROVED /
NOT APPROVED:
Reports outstanding / YES / NO / SIGNATURE:
DATE:
Ethics approval in place / YES / NO /
Outcome letter

MARK WITH AN “X” WHERE APPLICABLE

1. DETAILS OF APPLICANT
TITLE /
FIRST NAME
/
SURNAME
POSITION/RANK /
GENDER
DIVISION/CENTRE / RACE
(for reporting purposes only)
DEPARTMENT / DATE OF BIRTH
UT NUMBER / TEL (WORK)
E-MAIL(to be used for subsequent communication)

STAFF / STUDENT STATUS(Please mark the most relevant box with an X)

/ STAFF / POSTDOCTORAL FELLOW
STAFF ENROLLED FOR HIGHER DEGREE / POSTGRADUATE STUDENT
WILL THIS WORK LEAD TO A HIGHER QUALIFICATION? / NO / YES
(Specify)
Do you undertake to submit a report within 3 MONTHS of the conference?
Do you undertake to submit an article to an accredited journal within 6 MONTHS
of the conference?
Number of articles published in accredited journals during the past 3 years?
2. DETAILS OF CONFERENCE
OFFICIAL NAME
PLACE
DURATION / NO. OF DAYS /
FROM
/ YYYY/MM/DD /
TO
/ YYYY/MM/DD
NATURE AND AIM OF CONFERENCE AND CONNECTION WITH FIELD OF STUDY
INVOLVEMENT IN CONFERENCE
NO. OF APPEARANCES / INVITED SPEAKER / SPEAKER
(PAPER) / SPEAKER
(POSTER) / OTHER
(SPECIFY)
TITLE OF PAPER/POSTER
AUTHORS (Underline name of presenting author)
IS YOUR AFFILIATION ON THE ABSTRACT, PAPER / POSTER INDICATED AS STELLENBOSCH UNIVERSITY? / YES / NO
IS ETHICS APPROVAL REQUIRED? / YES* / NO** / ETHICS APPROVAL NUMBER / Expiry date
(MM/YYYY)
*IF YES, PLEASE ATTACH APPROVAL LETTER
**IF NO, BRIEFLY MOTIVATE
RESEARCH AREA OF PROJECT (Please mark the predominant area with an X; select only one)
INFECTIOUS DISEASES / MATERNAL & CHILD HEALTH
MENTAL HEALTH & NEUROSCIENCES / VIOLENCE, INJURIES, TRAUMA & REHABILITATION
HEALTH SYSTEMS STRENGTHENING / OTHER (please name):
NON-COMMUNICABLE DISEASES
3. ESTIMATED TOTAL COST

TRAVEL COSTS (as per SU Travel policy***):

AIR TRAVEL*** / RAND#
AIR TICKET
TRANSPORT TO AND FROM AIRPORTS
OTHER
ACCOMMODATION***
/ day(s) @ / R / per day
SUBSISTENCE***
/ day(s) @ / R / per day
REGISTRATION FEES
OTHER (Specify)
TOTAL
/ R
#Exchange rate used to convert to Rand (if applicable)
4. OTHER FINANCIAL SUPPORT FOR ATTENDANCE OF THISCONFERENCE
WHAT APPLICATION HAS BEEN MADE FROM OTHER SOURCES THAN THIS FUND
(Specify source and amount in each case)
WHAT HAS ALREADY BEEN AWARDED
(Specify source and amount in each case)

ARE YOU SUPPORTED BY A GRANT IN WHICH CONFERENCE TRAVEL IS ALLOWED AND BUDGETED FOR? (Specify source and amount in each case)

YEAR AND AMOUNT(S) OF YOUR LAST AWARD(S) FROM THEFUND FOR SCIENTIFIC TRAVEL / CONFERENCE(S) / NATIONAL / INTERNATIONAL
HAVE YOUR REPORT(S)BEEN SUBMITTED FOR THESE CONFERENCE(S) / SCIENTIFIC VISIT(S)? / YES / NO / YES / NO

I DECLARE THAT THE ABOVE DETAILS ARE CORRECT AND THAT, IF STELLENBOSCH UNIVERSITY MAKES A CONTRIBUTION, I WILL COMPLY WITH ALL THE CONDITIONS RELATED TO SUCH SUPPORT.

……………………………….………….………………………

APPLICANT SIGNATUREDATE

CONFIDENTIAL RECOMMENDATION FROM MANAGER – DIVISIONAL HEAD OR DIRECTOR OF CENTRE. (Please state clearly whether or not the application is supported). If the applicant is the executive Head of Department or Institute, s/he should indicate this below.

Please tick one:

Strongly supportedSupportedNot supported

  

Motivation (optional):

………………………………………………………………………………………………………………….

NAME AND RANK OF MANAGER (OR SUPERVISOR IN CASE OF STUDENT APPLICATION)

……………………………………………………..……………………………

MANAGER SIGNATUREDATE

1