JuniorDoctor

Research Fellowships

Application Form

Round Two

2016

Applications close 12 noonAEST 8 August 2016

Applicant’s name:

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JuniorDoctor Research Fellowships Application Form
Published by the State of Queensland (Queensland Health), April 2016

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) 2016
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 and Medical Research Unit, the Department of Health, GPO Box 48, Brisbane QLD 4001, email , phone +61 (0) 7 3328 9833.
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.
  1. Application instructions

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

Health and Medical Research Unit (HMRU), Healthcare Innovation and Research Branch, the Department of Health will call for applicationsinJune2016. This application will be assessed by an expert review panel against the selection criteria at Section 6 of the Junior Doctor Research Fellowship Funding Rules. The review panel is comprised of representatives from medical and research backgrounds.

1.1Submission of application

JuniorDoctor Research Fellowship submission
Step / It is recommended that applicants:
One / Read the JuniorDoctor Research Fellowships Funding Rules 2016

Two / Read JuniorDoctor Research Fellowships Legal Requirements 2016

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

1.1.1Application form

All applications must be submitted using this form (as per format at Section1.1.3)

1.1.2Closing date

Applications are to be submitted to the ail account by 12noon AEST 8 August 2016.Late applications will not be accepted.

If applicants have difficulty submitting applications, please contact the Department of Health on telephone +61 7 3328 9833 to make alternative arrangements.

1.1.3Format of lodgement

The application will be submitted in a single Adobe Acrobat Portable Document Format (.pdf). Please ensure that the software used is compatible with version 11 of Adobe Acrobat.

Applicants will submit their application on this form using:

  • Arial 10.5 point
  • Single-spaced font
  • 2 cm page margins.

The application form must be submitted in its original form by the junior doctor. Applicants are not permitted to edit the underlying template of the application form.

Submissions require completion of this application form. Where there is no response to a question, please indicate ‘not applicable’.

1.1.4Naming the file

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

HMR_Junior_SURNAME_FIRSTNAME.PDF

1.1.5Attachments

Applicants should include their Curriculum Vitae and official academic transcript in one PDF attachment with the file name – the surname and first name refers to the applicant:

Attach_HMR_Junior_SURNAME_FIRSTNAME.PDF
  1. Personal details of applicant

Personal details of applicant
Family name
Given name(s)
Title / (Prof, Dr, Mr, Mrs, Ms etc)
Gender / Male/Female
Postal address
Suburb/town
State
Postcode
Country
Courier address (Line 1)
Courier address (Line 2)
Suburb/town
State
Postcode
Country
Work phone number
Applicant’s mobile phone number
Email address (contact is via email in the first instance)
Secondary mail address
Citizenship/resident details of applicant
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.
Equal employment/diversity information – please indicate if you (the applicant) identify with any of the following groups. The completion of this section is voluntary.
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. Qualifications of applicant

Academic/research qualifications – Copy and paste the table below as many time 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)
Other health profession registration/s (e.g. Nurse, Physio) and registration number
  1. Current appointments of applicant

Copy and paste the table below as many times as required for each separate appointment.

Current appointments and research appointment/s
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/part time/contract)
  1. Other Research Funding Awarded or Requested

Acceptance of a Junior Doctor Research Fellowship may impact on the continuance of other research funding already held and/or requested. Please detail belowall current or requested research funding. Please indicate if any of this funding would need to be relinquished if successful in gaining a Junior Doctor Research Fellowship.

Current or requested research funding
  1. Nominated Mentorand Supervisor

Applicants for Round Two must nominate a mentor and a supervisor to provide guidance for and management of their Fellowship. Applicants must choose amentor and a supervisor.

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. The Fellow’s mentor must reside and conduct research activities in Queensland.

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. The Fellow’s supervisor must reside and conduct research activities in Queensland.

Mentor and supervisor details are to be provided in the appropriate sections below. Mentor and supervisor acceptanceand certification are to be provided in Section 10 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 Applicant
Permission to contact / Yes/No
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 Applicant
Permission to contact / Yes/No
  1. Fellowship engagement

Please nominate your preference for engagement in the Junior Doctor Research Fellowship Program below.

Fellowship Participation
Full-time / Part-time / No Preference
If part-time please indicate % time for Fellowship Participation: %
(Note that a 50% minimum participation is required)
  1. Selection Criteria and Referees

Applications are assessed by the review panel, according to three assessment criteria as outlined in Section 6 of the Junior Doctor Research Fellowship Funding Rules.

8.1CV and Academic Transcript

Include a CV and copy of your official academic transcript in PDF format.

8.2Rationale for applying for a Junior Doctor Research Fellowship

Include a rationale on why you want a Junior Doctor Research Fellowship(not more than 500 words) and how your experience and track record make you an ideal candidate.

In your rationale include your preference for start date for your fellowship if you are successful. This must be no later than 30 January 2017.

Outline why you want a Junior Doctor Research Fellowship and how your experience and track record make you an ideal person for a Fellowship
(Arial 10.5 point, single-spaced font)
  1. Referees

Applicants are required to include contact details (email and phone number) of two referees. You must seek approval prior to nominating a person as a referee. Referees should have a thorough knowledge of your work performance and conduct, and it is preferable to include your current/immediate past supervisor. By providing the names and contact details of your referees you consent for these people to be contacted by the selection panel.

Referee 1
Title / Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Name of employing organisation
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact / Yes / No
Referee 2
Title / Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Name of employing organisation
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact / Yes / No
  1. Certification

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

Applicant’s certification
Title / Prof, Dr, Mr, Mrs, Ms etc
Last name / Applicant's last name
First name(s) / Applicant's first name
Signature
Date / [DD/MM/YYYY]

I, agree to act as a Mentor for [insert Applicant's name] should the Applicant 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 Applicant's name] should the Applicant 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]
  1. Checklist before submission

Before submitting your application you must confirm that you have:

Completed each section of the application form

Certifications section signed using original signature.

Application document (including signed certification) included in the one PDF format file using the naming convention: HMR_Junior_SURNAME_FIRSTNAME.PDF

Attached curriculum vitae and academic qualifications (certified copy of official transcripts) in the one PDF format file using the naming convention: CV_Junior_SURNAME_FIRSTNAME.PDF.

Department of Health
Junior DoctorResearch Fellowship – Application form R2 19.04.2016.doc

JuniorDoctor Research Fellowships Application Form (Round Two) / 1