/ STELLENBOSCH UNIVERSITY
FACULTY OF MEDICINE AND HEALTH SCIENCES /

SCIENTIFIC TRAVEL & PUBLICATION INCENTIVE FUND
SCIENTIFIC TRAVEL: RESEARCH VISIT APPLICATION FORM (STV-2017-06)

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

(b)This application should be completedELECTRONICALLY.

(c)The following supporting documents or copies of these documents should be attached to the application and labelled as follows:

Appendix 1:Anofficial invitationby the host at the host institution.

Appendix 2: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 3:A numbered list of all publications, with complete references, for the previous 3 yearsin the category of (i) journal articles, (ii) 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 4:A written quotation in respect of the accommodation costs during the scientific visit.

Appendix 5:A written quotation from a travel agency in respect of the cheapest air-travel tariff. Such quotation should apply to the ACTUAL number of days of THe visit (even if additional travelling/visits are undertaken with financing from other sources).

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

PLEASE NOTE:Should your research visit include a conference presentation, please submit details of the conference, your abstract and proof of acceptance of your abstract together with this application(there is no need to complete an additional application should this information be provided here).

(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). In the case of postgraduate students a recommendation from the supervisor (promoter) will suffice.

APPLICATIONS SHOULD BE SUBMITTED BEFORE THE INTENDED VISIT AND THE DEPARTURE DATE MAY NOT PRECEED THE CALL DEADLINE DATE. 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: RESEARCH VISIT APPLICATION FORM (STV-2017-06)

CHECKLIST:

International research visit of less than 2 months

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

REQUIREMENTS / YES / NO / IF NO, PLEASE CLARIFY
OFFICIAL invitation from the host institution to you
Numbered list of all conference papers with complete references,
for the previous 3 years
Numbered list of all publications with complete references, for the previous 3 years
Written quotation of accommodation costs
Written quotation of air travel costs 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 SCIENTIFIC VISIT
HOST’S NAME / INSTITUTION
PLACE
DURATION / NO. OF WEEKS /
FROM
/ JJJJ/MM/DD /
TO
/ JJJJ/MM/DD
REASON FOR VISIT / OBJECTIVES OF VISIT
EXPECTED OUTCOMES
PURPOSE (Mark all applicable boxes with an X)
Collaborative Research Project / Investigate collaboration / Research Training / Conference presentation / Other
(Specify)
EXPLAIN HOW THIS VISIT WILL ADVANCE YOUR RESEARCH AND/OR WHY THIS CAN NOT BE ACHIEVED WITHIN SOUTH AFRICA
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/days @ / R / per day
SUBSISTENCE*
/ day/days @ / R / per day
REGISTRATION FEES
OTHER (Specify)
TOTAL
/ R
**Exchange rate used to convert to Rand (if applicable)
4. OTHER FINANCIAL SUPPORT FOR THIS SCIENTIFIC VISIT
WHAT APPLICATION HAS BEEN MADE FROM OTHER SOURCES THAN THIS FUND
(Specify source and amount in each case)
WHAT HAS ALREADY BEEN ALLOCATED
(Specify source and amount in each case)

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

YEAR AND AMOUNT(S) OF YOUR LAST AWARD(S) FROM THIS FUND FOR SCIENTIFIC TRAVEL / CONGRESS(ES) / 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