JuniorDoctor

Research Fellowships

Application Form

Round Three

2017

Applications close 12 noonAEST 11August 2017

Applicant’s name:

JuniorDoctor Research Fellowships Application Form(Round Three)

Published by the State of Queensland (Queensland Health), 2017

This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au

© State of Queensland (Queensland Health) 2017

You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health).

For more information contact:
Health Innovation, Investment and Research Office, Department of Health, GPO Box 48, Brisbane QLD 4001, email , phone +61 (0) 7 3708 5071.

An electronic version of this document is available at

Disclaimer:
The content presented in this publicationis distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information.

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  1. Application instructions

Before completing this form, please ensure that you have read all relevant documentation outlined below.

This application will be assessed by an independentreview panel against the selection criteria at Section 4 of this form. The review panel is comprised of representatives from medical and research backgrounds.

1.1Submission of application

JDRF submission
Step / It is recommended that applicants:
One / Read the Junior Doctor Research Fellowships Funding Rules 2017

Two / Read the Round 3 JuniorDoctor Research Fellowships Frequently Asked Questions

Three / Read the Queensland Health Research Fellowship Funding Agreement Terms and Conditions (version 2017 Round 3 JDRF)

Four / Complete this application form (JuniorDoctor Research Fellowships Application Form (Round Three 2017))
Five / Submit application to

1.1.1Closing date

Applications are to be submitted to the ail account by 12pm AEST 11 August 2017.Late applications will not be accepted.

If applicants have difficulty submitting applications, please contact the Department of Health on telephone +61 7 3708 5071to make alternative arrangements.

1.1.2Format of lodgement

The application should be submitted in a single PDF file.

Applicants will submit their application on the form provided using Arial 10.5 point and single-spaced font.Where there is no response to a question, please indicate ‘not applicable’.

The application form must be submitted in its original form by the applicant. Applicants are not permitted to edit the underlying template of the application form (unless where indicated).

1.1.3Naming the file

The following naming convention should be used in thedocument file name (do not include spaces) – the surname and first name refers to the applicant (the proposed Fellow):

HIIRO_JDRF_SURNAME_FIRSTNAME.PDF

1.1.4Attachments

Applicantsshould include their Curriculum Vitae (CV) and official academic transcript in one PDF attachment with the file name:

ATTACH_HIIRO_JDRF_SURNAME_FIRSTNAME.PDF
  1. Applicant details

The proposed Fellow
Title / (Prof, Dr, Mr, Mrs, Ms etc)
Surname
First name(s)
Gender / Male/Female
Work address
Suburb
State and Postcode
Work phone number
Mobile phone number
Email address (contact is via email in the first instance)
Citizenship
Primary place of residence
If not an Australian citizen, please indicate if you are a permanent or temporary resident, or hold a Special Category Visa (please provide certified copies of relevant documentation).
If not a holder of the above, has a residency permit or a Special Category Visa been sought? Please provide details.
Academic/ research qualifications
(Copy and paste rows below as many times as required)
Academic qualification (e.g. BSc, MSc, PhD)
Institution
Year
Topic/Majors
Medical status
Medical Practitioner registration number
Current appointment level (e.g. JHO, PHO)
Current appointments and research appointment/s
(Copy and paste rows below as many times as required)
Job title (e.g. Doctor, Research Fellow)
Organisation (e.g. Metro North Hospital and Health Service)
Location (e.g. Royal Brisbane and Women’s Hospital)
Current status of position (e.g. permanent full time/temporary full time or part time/contract FTE%)
Current employment status
Name of current employer
Proposed fellowship participation
Fellowship duration / Minimum duration is two years; maximum duration is four years
Full-time / Part-time / No Preference
If part-time, please indicate % time for Fellowship Participation: %
(Note that a 50% minimum participation is required)
Current or requested research funding
Acceptance of a JDRF may impact on the continuance of other research funding already held and/or requested. Please detail all current or requested research funding. Please indicate if any of this funding would need to relinquished if successful.
Equal employment/diversity information – please indicate if the applicant identifies with any of the following groups.
People with a disability / Yes/No
People from a non-English speaking background / Yes/No
Aboriginal / Yes/No
Torres Strait Islander / Yes/No
Australian South Sea Islander / Yes/No
  1. Fellowship summary

Project summary
Proposed fellowship commencement date / Must be a date in 2018 and no later than 30 April 2018 (to be confirmed if application is successful)
Project title / No more than 20 words
Main project location / Primary location of project activity
Other project locations / Other research locations
  1. Selection criteria

Applications are assessed by the independentreview panel, according to the assessment criteria as outlined below.

4.1Personal achievements (35%)

Applicants should include a CV and copy of theirofficial academic transcript in PDF format.

Personal achievements
Must be no more than 500 words. Outline academic qualifications, research experience and professional skills. Include any key or major publications, conference presentations, prizes and awards.

4.2Rationale (35%)

Rationalefor applying for a JDRF
Must be no more than 500 words. Rationale for why the applicant is a good candidate for a JDRF, and how their experience and track record make them an ideal candidate. Include comment on potential for and/or aspiration to a career as a clinician researcher. Include information on the relevance of the nominated supervisor and research environment for the proposed research.

4.3Significance and feasibility of proposed research project (30%)

Brief research project plan
Must be no more than 2 pages. Please provide:
1) an overview of the proposed research
2) the need for the research
3) the aims of the research
4) key research questions
5) a general outline of the proposed methodology
6) any relevant research collaborations
7) opportunities for translation of research outcomes into clinical practice
8) the likely outcomes for Queensland within the next five to ten years
Ethical considerations
Ethical implications of the research. Please provide detail on relevant ethics approvals (e.g. Human Research Ethics Committee (HREC).
Project research milestones
List the key or major project research milestones and completion times (e.g. number of months from commencement). The successful Fellow will report on progress in completing the milestones annually.
(Copy and paste rows below as many times as required)
Milestone 1 / Description / Due date
Milestone 2 / Description / Due date
Milestone 3 / Description / Due date
Project expenditure table
Outline an approximate budget for the proposed project, showing expenditure over the Fellowship of the funds provided.
(Columns for Year 3 and Year 4 are only to be completed ifthe proposed duration of the research project is longer than the minimum of two years)
Expenditure / Year 1 / Year 2 / Year 3 / Year 4
Fellow’s salary
Other technical/research assistants
Project consumables
Travel
Other project expenditure
TOTAL
Please note below if there are any likely contributions from other funding sources.
  1. Nominated Mentor and Supervisor

Applicantsmust nominate a mentor and a supervisor to provide guidance for and management of their Fellowship. Both the mentor and the supervisor must reside and conduct research activities in Queensland.

A mentor is a person who has significant experience in the development and implementation of research that is relevant to the Fellowship. The mentor is expected to provide guidance of a strategic nature through all stages of the Fellowship.

A supervisor is a person who has experience in the development and implementation of research that is relevant to the Fellowship. The supervisor is expected to provide an active management rolethrough all stages of the Fellowship on a day to day basis.

Mentor and supervisor details are to be provided in the appropriate sections below. Mentor and supervisor acceptance and certification are to be provided in Section 7 of this Application Form.

Mentor details
Title / Prof, Dr, Mr, Mrs, Ms etc
First name, surname
Research field
Academic qualifications
Clinical qualifications
Institute / Hospital/university etc
Office phone number
Mobile phone number
Email address
Relationship to proposed Fellow
Supervisor details
Title / Prof, Dr, Mr, Mrs, Ms etc
First name, surname
Research field
Academic qualifications
Clinical qualifications
Institute / Hospital/university etc
Office phone number
Mobile phone number
Email address
Relationship to proposed Fellow
  1. Referees

Applicantsare required to include contact details of two referees. The applicant must seek approval prior to nominating a person as a referee. Referees should have a thorough knowledge of the proposed Fellow’s work performance and conduct, and it is preferable to include a current/immediate past supervisor. By providing the names and contact details of referees,the applicant consents for these people to be contacted by the independent review panel.

Referee 1
Title / Prof, Dr, Mr, Mrs, Ms etc
First name, surname
Name of employing organisation
Office phone number
Mobile phone number
Email address
Relationship to proposed Fellow
Referee 2
Title / Prof, Dr, Mr, Mrs, Ms etc
First name, surname
Name of employing organisation
Office phone number
Mobile phone number
Email address
Relationship to proposed Fellow
  1. Certification

I, the Applicant, certify that all details given in this application are correct.

Applicant’s certification
Title / Applicant's details
Surname / Applicant's details
First name(s) / Applicant's details
Signature
Date / [DD/MM/YYYY]

I, agree to act as a Mentor for [insertproposed Fellow's name] should they be awarded a Junior Doctor Research Fellowship.

Mentor’s certification
Title / Mentor's details
Surname / Mentor's details
First name(s) / Mentor's details
Signature
Date / [DD/MM/YYYY]

I, agree to act as a Supervisor for [insert proposed Fellow's name] should they be awarded a Junior Doctor Research Fellowship.

Supervisor’scertification
Title / Supervisor's details
Surname / Supervisor's details
First name(s) / Supervisor's details
Signature
Date / [DD/MM/YYYY]
JuniorDoctor Research Fellowships Application Form (Round Three 2017) / 1