Application: 2018 Fellowship Expression of Interest – BioMed City

Application for:

Fellowship category / Intended Research Group (if relevant)
Select one of the following:
Early Career Fellowship (ECF) – 2 Years
Mid-Career Fellowship (MCR) – 3 Years / Program/Research Group you propose to work in:
Head of Research Group:
Primarydiseaseorcondition being researched:

NOTE: Grant Period: 1 July 2018 – 30 June 2020 (ECR) or 30 June 2021 (MCR)

______

Applicant details

Title:Firstname:Initial:Last name:

Institution Name:

School/Centre/Institute:

Faculty:

Full Postal Address – work (including DX#):

PhoneNumber:

E-mailAddress:

Appointment held, including year of appointment:

Current position renewal date:

Date of Award of Higher Degree:

Number of years’ research experience post PhD:

Research Experience:

Institution / Position title / Research activities (short description) / Inclusive dates worked

Other research grant information

(1)

Grants currently held by the applicant as first named investigator (at time of submission of the application) / Period of support (from – to) / Funds / Source

(2)

Grants requested by the applicant as first named investigator (for 2019) / Period of support (from – to) / Funds / Source

(3)

Grants held by the applicant as first named investigator (during the past 7 years) / Period of support (from – to) / Funds / Source

Applicant Curriculum Vitae (including all publications)

(Please attach to application when submitting to

Minimum 10 point font size

Track record

Describe your Academic & Research Highlights and any experience in innovation and collaboration (no more than 500 words)

Opportunity to make a statement regarding Track Record relative to opportunity(no more than 300 words)

Project details

ProjectTitle:

Using lay terms, please detail the expected outcome of the research including who will benefit and why there is a need in the community. How is this project translating science to healthcare? (no more than 500 words)

Please provide an overview of the project. This section allows you to providegreater detail addressing:

  • General approach and significance:
  • Overview (Including Aims and Objectives)
  • Details (including Innovation and Novelty, Level of Scientific Excellence, & Collaboration objectives)
  • Expected outcome of the proposed research, level of potential Community Impact, translational opportunities:

(no more than 1000 words)

Milestones

Pleaseindicateyourkeymilestones that align with your research plan,alongwiththecompletiondateandassociatedcosts. Include any expected travel components. Please note, you will be expected to provide progress reports to THRF at the end of each milestone.THRF will provide awarded recipients with a template for this.Travel expenses are capped at $15,000 total (over 3 years) and are subject to approval by research group leader/head of department.

Milestone / Timeline

Budget Items

Personnel / 2018 - 2019 / 2019 - 2020 / 2020 - 2021 (relevant for Mid-Career) / Total
Salary
(Indicate Level)
On-costs
Travel (capped at $5,000 pa)
Consumables
(Itemise)

Supervisor/Manager Statement

THRF EARLY CAREER / MID CAREER FELLOWSHIP

Applicant Name:

Supervisor/Manager names, position, contact details:

Potential Supervisor/Manager, please provide a concise summary of your group’s research interests and directions, how the group is currently performing, its research capability, and the planned role for the applicant within the group/BHI. Please also outline your view on the applicant relative to his/her peers and/or to previous individuals’ whom the supervisor has supervised (top 10%, bottom 10% etc)(no more than 500 words)

Proposed AdministeringInstitution

Organisationname:

ABN:

ContactPerson:

PhoneNumber:

E-mailAddress:

PostalAddress:

Certifications and Approvals

Ethical Implications of the proposed research

Does this research involve any of the listed activities:

Experimentation on human subjects?Yes/NoProvide copy of the current approval.

Experimentation on animals?Yes/NoProvide copy of the current approval.

Use of GMO/GM productsYes/NoProvide copy of current OGTR approval

Copies of the above approval must be submitted with application to .

Signature of Applicant

I declare that the information supplied on this application, and any accompanying documentation to be true and correct.

If I am successful in obtaining a grant, the research will not commence until it has been approved by the relevant institutional committee/s.

Printed name of Applicant:

Signature of Applicant ______

Date//201

Certification by the Director of Research, CALHN

Certification by the Director of Research, Central Adelaide Local Health Network (CALHN)

I acknowledge that this EOI will be forwarded to the Director of Research for CALHN, Professor John

Beltrame to certify that the project is appropriate to the general research facilities of the RAH and/or SA Pathology

(Please circle the below)

Yes / No