2017 MRSP speciaL inFrastructure SCHEME

emcr EQUIPMENT

GRANT application FORM

Please return completed application to

Nominations close 5:00pm, Wednesday 7 June 2017

  1. ChiefInvestigator (C1) information

Title / Click or tap here to enter text. /
Given Name (s) / Click or tap here to enter text. /
Surname / Click or tap here to enter text. /
Current position / Click or tap here to enter text. /
Level of Appointment (e.g. Level A.8) / Click or tap here to enter text. /
Commencement date of current appointment / Click or tap here to enter text. /
End date of current appointment / Click or tap here to enter text. /
Appointment Full Time Equivalent
(e.g. 1.0FTE; 0.2FTE) / Click or tap here to enter text. /
HMRI Research Program / Click or tap here to enter text. /
Email / Click or tap here to enter text. /
Telephone / Click or tap here to enter text. /
Gender / Click or tap here to enter text. /
Investigator Career Status / ☐ ECR
[must be within 5 years post-PhD at time of nomination (i.e. PhD must have been conferred after 7/06/12 – or career interruption detail provided below)] / ☐ MCR
[must be within 5 – 15 years post-PhD at time of nomination (i.e. PhD must have been conferred after 7/06/02 but before 7/06/12 – or career interruption detail provided below)]
Date PhD conferred / Click or tap here to enter text. /
Career Interruption (if applicable)
Please outline detail of career interruption(s) due to specified career and life experiences including detail on length of interruption(s) in months. / Click or tap here to enter text. /
☐ I would like to be added to an email list to receive further information on consultation opportunities and initiatives for HMRI-affiliated early and mid-career researchers.
  1. ADDITIONAL CHIEF INVESTIGATORS

Please copy and paste the BELOW table to include additional CHIEF investigators

Title / Click or tap here to enter text. /
Given Name (s) / Click or tap here to enter text. /
Surname / Click or tap here to enter text. /
Current position / Click or tap here to enter text. /
HMRI Research Program / Click or tap here to enter text. /
Email / Click or tap here to enter text. /
Telephone / Click or tap here to enter text. /
Gender / Click or tap here to enter text. /
Investigator Career Status / ☐ ECR
[must be within 5 years post-PhD at time of nomination (i.e. PhD must have been conferred after 7/06/12 – or career interruption detail provided below)] / ☐ MCR
[must be within 5 – 15 years post-PhD at time of nomination (i.e. PhD must have been conferred after 7/06/02 but before 7/06/12 – or career interruption detail provided below)]
Date PhD conferred / Click or tap here to enter text. /
Career Interruption (if applicable)
Please outline detail of career interruption(s) due to specified career and life experiences including detail on length of interruption(s) in months. / Click or tap here to enter text. /
☐ I would like to be added to an email list to receive further information on consultation opportunities and initiatives for HMRI-affiliated early and mid-career researchers.

Note: A two (2) page Track Record Statement must be attached for every Chief Investigator listed in this application

3. equipment details

summary of equipment

Please provide a brief high-level lay summary of the proposed minorequipment or general infrastructure(500 words)

This should address:

  • Itemised details of the general infrastructure and/or minor equipment (including name and make of equipment) and broad research use
  • The proposed location of the minor equipment and general within the HMRI Building or other location (include Building, Level and Specific Room)

Click or tap here to enter text.

proposed management plan

If applicable, please outline the management and maintenance requirements for anyminor equipment requested in this application. Include details of the estimated annual maintenance and repairs costs and propose how these costs will be managed. Please outline if this is not applicable. (500 words)

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4. assessment criteria

Provide a summary of the EMCR research team listed on the application and a description of how this funding will help build research capacity and support current and future research projects. Preference will be given to applications that support teams led by EMCRs, or contribute to EMCR collaborations across HMRI Research Programs, UON PRCs, Hunter New England Local Health District, and/or with industry and end-users.

Note: Two (2) page Tack Record Statement for all listed Chief Investigators must also be attached to the application

EMCR Name / HMRI Program / UON PRC
(if applicable) / Description of how this funding will help build research capacity and support current and future research projects
CI1 / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. /
CI2 / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. /
CI3 / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. /
CI4 / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. /
CI5 / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. /
CI6 / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. / Click or tap here to enter text. /

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Please outline how the minor equipment or general infrastructure will assist to leverage other external funding (for example, NHMRC Project Grant funding) (500 words)

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If applicable, outline how you have ensured that the requested equipment can be accommodated in the existing floorspace of the location proposed, including any changes to, requirement for, or interfacing with existing building services infrastructure and how these costs will be managed (where in doubt the specifications should be discussed with the HMRI Facilities Manager, or equivalent representative for alternative sites); and how the maintenance and repairs for any minor equipment requested in this application will be funded.(300 words)

Note: Detail is only required if requesting funds for a large item of equipment.

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5. EQUIPMENT budget

equipment budget TABLE

Please provide a detailed budget (GST exclusive), itemising the costs of all minor equipment and general infrastructure being request - including any shipping, installation and maintenance costs, if applicable.

Note:

  • A maximum of $10,000 can be requested
  • Funds cannot be used to co-fund larger items of equipment unless HMRI purchases and owns the equipment.

MINOR EQUIPMENT OR GENERAL INFRASTRUCTURE DESCRIPTION / $
1. / $ /
2. / $ /
3. / $ /
4. / $ /
5. / $ /
(A) EQUIPMENT COSTS SUB-TOTAL / $ /
Other funding contributions towards equipment (IF APPLICABLE)
Please detail source 1 (e.g. Industry/External) / $ /
Please detail source 2 (e.g. UoN-other/Industry/External) / $ /
(B) OTHER FUNDING CONTRIBUTIONS SUB-TOTAL / $ /
TOTAL AMOUNT REQUESTED FROM THIS GRANT (A – B) / $ /

Note:Quote(s) and evidence of other funding contributions must be attached to this application.

budget JUSTICATION

Please provide a justification of all budget items for which you are requesting HMRI EMCR Equipment Grant funding. Items must be justified under the budget line descriptions used in the above table (500 words)

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CHIEF INVESTIGATOR (CI1) CERTIFICATION
As Chief Investigator, I confirm the following:
  • I certify that all information included in this application is true and correct.
  • I confirm that I am not listed on any other HMRI EMCREquipment Grant application
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Signature Date
additional chief INVESTIGATOR (CI2)CERTIFICATION
As Chief Investigator, I confirm the following:
  • I have agreed to be included on this proposal and have reviewed the application.
  • I am not listed on any other HMRI EMCR Equipment Grant application
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SignatureDate
Please copy and paste table to include all signatures for all additional chief investigators
HMRI PROGRAM LEADER CERTIFICATION
As HMRI Program Leader of Chief Investigator (CI1), I confirm the following:
  • I certify that I have reviewed the application and support the minor equipment and/or general infrastructure items requested.
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Signature Date
APPLICATION CHECKLIST
As Chief Investigator, I confirm the following:
☐ All sections of the Application Form are complete
☐ All listed Chief Investigators have Certified this application
☐ Thehead of my HMRI Research Program has reviewed and certified theApplication Form
☐ I have attached: Two (2) page Track Record Statements for all Investigators listed on application
☐ I have attached: Quote(s) for all equipment/infrastructure costs detailed in the ‘Equipment Budget Table’
☐ I have attached: Evidence of other funding support outlined ‘Equipment Budget Table’ (if applicable)

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