Chief Scientist Office

Postdoctoral Fellowship in Health Services and Health of the Public Research
Application form / CSO reference number:
PDF/15/

Please complete this form in Verdana 10 point font size

1. Personal Details

Title and name
Address
Email
Telephone
Current Position
Qualifications

2. Summary of proposed fellowship

Title of Research Project:
Host institution and Department/Division
Total Amount of Support requested
Start Date
End Date
Full/part time (if part time state proposed WTE)
Primary keyword
Secondary keywords
This (or a similar)applicationhas been, or is currently being, submitted to:

3. Details of present position

Post Title
Name and Address of Current Employing Organisation
Grade
Present Basic Salary
Date of Expiry of Current Contract

Applicants who are currently employed in clinical duties should describe below the arrangements for any clinical duties that are to be retained

4. Academic and Job History

a. Academic Qualifications

Qualification (and class if relevant) / Subject / Institution / From / To

b. Professional Qualifications

Qualification / Subject / Institution / From / To

c. Employment history

Position / Employer / From / To

5. Research History

a. Doctoral research

Please give details of research in the higher degree(s) you have completed

b. Postdoctoral research

Briefly describe any research you have undertaken at postdoctoral level

c. Publications

Please give details of research publications and published abstracts

d. Grants obtained

e. Additional information

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6. Research

a. Abstract

Include a summary of the objectives, design, techniques/approaches, measurements/outcomes of the research in not more than 250 words

b. Lay summary

Provide a statement in not more than 150words, which will explain to a lay audience the nature of the proposed research, the prospective outcomes and the expected benefits in terms of improvement to health

c. Research Proposal(no more than 4 pages using the headings detailed in the guidance notes) and key references

7. Details of Proposed Training (copy tablefor additional courses if required)

Name of Course
Institute
Formal qualification awarded
Details of the qualification
Planned date(s) of attendance
Name of Course
Institute
Formal qualification awarded
Details of the qualification
Planned date(s) of attendance
Name of Course
Institute
Formal qualification awarded
Details of the qualification
Planned date(s) of attendance

In no more than one page please explain what has prompted your choice of training course(s), and what skills you expect to acquire through this training.

8. Career Intentions

In no more than one page please state your reasons for applying for this award, how it will help you become an independent researcher and your long term career plans

9. Mentoring Arrangements

Mentor

Name
Institution
E-mail address
Brief summary of research skills
Details of Research Supervision/mentoring experience
Current supervisory/mentoring load
How the mentoring will be organised and will contribute to the development of the Fellow

10. Details of Finance Requested (all to be apportioned by financial year ending 31 March)

Year 1
2015-16 / Year 2
2016-17 / Year 3
2017-18 / Year 4
2018-19 / TOTAL
Gross Salary:
Superannuation:
Employer's NI Contribution:
Training Costs – detailed breakdown:
Research costs – detailed breakdown:
(justification attached if necessary)
Alternative sources of funding being sought (if applicable):
SUB TOTAL:
TOTAL including 25% overhead
NHSScotland Support Costs*
(if being incurred)

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11. Declarations and authorisations:

a) Applicant:

To my knowledge the research described here represents the ideas, concepts and writings myself and my supervisors.

Name (Capitals) / Signature / Date

b) Mentor:

To my knowledge the research described here represents the ideas, concepts and writings of the applicant and I confirm that the applicant has discussed and agreed the mentoring requirement with me.

Name (Capitals) / Signature / Date

c) Sponsor(s):

I agree to be sponsor/co-sponsor/joint sponsor (delete as appropriate) for the research undertaken during this Fellowship under the requirements of the Scottish Executive Health Department’s Research Governance Framework for Health and Community Care.

Signature (for and on behalf of the Sponsor Organisation) / Name and Organisation (Capitals) / Date

d) Grantholder:

This application should be signed by (i) the Head of Department and (ii) the officer who will be responsible for administering the Fellowship if it is awarded.

“I confirm that I have read this application and that, if successful, the work will be accommodated and administered in this Department/Institution in accordance with CSO’s Standard Conditions of a Research Training Fellowship. I accept responsibility for the conduct of this Fellowship and funds awarded for it and shall immediately inform CSO if there is any indication of scientific misconduct or misuse of funds”

i) Head of Department:

Signature / Date
Title and full name (block capitals) / Department

ii) Finance Office of Grantholder:

Signature / Date
Title and full name (block capitals) / Position held
Address
Postcode
Telephone no./ext. / Fax no.

e) NHS R&D Officer

When NHSScotland Support Costs are identified, the relevant NHS R&D Officer(s) must sign the following:

This application has been discussed with me and I note the associated NHSScotland Support Costs.

Signature / Date
Title and full name (block capitals) / Position held
Address
Postcode
Telephone no./ext. / Fax no.

ANNEX A

R&D Project Details Pro forma

1.Principle research question

2.Methodology:

(please tick)

Clinical trial
Randomised controlled trial (specify comparison groups
below)
Systematic review
Case-control study
Other (please specify in free text)

3. Sample group description (the notional population from which the sample is drawn for the purposes of your study)

4. Outcome measure description (endpoints or factors used to evaluate health status, such as survival discharge status or quality of life. Can also be a symptom e.g.reduction in blood pressure.)

5. Project related web site (the address for a web site which contains further related information for an individual project)

ANNEX B

Reviewer nomination form

CSO reference number:PDF/15/

Applicant
Title of application
Title and name
Current post
Full postal address
E-mail:
Title and name
Current post
Full postal address
E-mail:
Title and name
Current post
Full postal address
E-mail.:
Equal Opportunities Monitoring (Annex C) / CSO reference number:
PDF/15/

Data on gender, ethnic origin and disability status is collected to ensure the effectiveness of CSO’s equal opportunities policy. We want to ensure that all applicants are treated equally. To do this we need to know more about the people who apply to us and would be grateful if you would complete the following questions.

This form should be completed in respect of the Applicant and mentor The form(s) will be separated from your application form on receipt and used solely to evaluate the effectiveness of CSO’s equal opportunities policy. The information will not be made available to external referees or peer review bodies and will not affect the processing of your application in any way.

Personal information:

Full Name / Age / Gender
(Male/Female)

Type of application:

Outline / Full Grant/ Other / Small Grant
Clinical Academic Training Fellowship / X

Please indicate whether you are the Applicant (PA) or Supervisor (Co-Ap):

PA / Co-Ap

What is your ethnic group?

Choose one section and then tick the appropriate box to indicate your cultural background.

WhiteMixed

□ Scottish□ Any Mixed background

□ Other BritishPlease write in

□ Irish______

□ Any other White background

Please write in

______

Asian, Asian Scottish or Asian BritishBlack, Black Scottish or Black British

□ Indian□ Caribbean

□ Pakistan□ African

□ Bangladeshi□ Any other Black background

□ ChinesePlease write in

□Any other Asian background ______

Please write in

______

Other ethnic background

□ Any other background

Please write in

______

Are you registered disabled?

Yes / No

Signature: ______

Date:______

From time to time we may be asked to provide information, on gender, ethnic origin and disability, in response to Parliamentary Questions and other public enquiries. Any information provided will only be used in ways that do not allow individuals to be identified personally.