RESEARCH SUPPORT SHORT Form

Office Use Only
Ref. No.

This application form must be completed with reference to the Wesley Medical Research Support Program Guidelines and Frequently Asked Questions (available at

Applications must be submitted to:

Please direct any inquiries to:

Research Theme / Theme Leader / Contact information
Cancer / Ms Emma Raymond / T: 07 3721 1542
E:
Women’s and Children’s Health
Cardiology and Cardiac Surgery / Dr Kelley Foster / T: 07 3721 1503
E:
Neuroscience
Infections and Critical Illness / Ms Angela Tapuni / T: 07 3721 1545
E:
Surgical and Medical Innovations
Rural & Remote Health / Dr Tamara Street / T: 07 3721 1706
E:
  1. Contact Information

The Chief Investigator must be a doctor or other health professionalworking on the campus of a UnitingCareHealth Hospital.

Title/First Name/Last Name
Current Appointment
Department and Institution
Postal Address
Work Telephone
Mobile
E-mail address
Highest academic/
professional qualification

Copy table and repeat for each additional investigator.

  1. Project Title (short descriptive title)
  1. Indicate the theme of your research study

Neuroscience Cancer Cardiology and Cardiac Surgery

Infections and Critical Illness Rural and Remote Health

Surgical and Medical Innovations Women’s and Children’s Health

  1. Aims, expected outcomes and benefits

Please outline in layman’s language the problem/question, the aims, expected outcomes and benefits of the project (250 word limit). This will be used to attract / identify external financial support for the project.

  1. Novelty and future impact (address novelty, inventiveness, utility)

E.g. commercial opportunities, cost savings, public good (e.g. large medical need), competitive advantage, etc.

(200 word limit)

  1. Clinical Practice Translation

Explain how your research would lead to improvements in patient care or quality of life within 5 years of initiation of the project (200 word limit).

  1. Background & Rationale (what isalready known and why there is a need for this study) Include references from your literature review to support the description.
  1. What you are trying to achieve(include precise aims/hypotheses/research question)
  1. Research Plan(study design, number of participants, the rationale for that number, what is required of participants, where the research will be conducted, how the information you receive will be analysed/interpreted and reported)
  1. Commencement / completion of the proposed project

Has the project started? / Yes / No
If NO, when will it start? (mm/yy) / / / If YES, when did it start? / /
How long will this project take? (number of years)
Short Form / Date: 03/04/2017
Version: 2.0 / Page 1 of 7
  1. Supportrequested from Wesley Medical Research

List project activities to be carried out within each milestone (limit to 4 milestones). Include what WMR resource will be required to perform each project activity and how many hours will be involved (associated costs will need to be determined in consultation with the relevant Theme Leader). Direct funding will only be considered if the resource is not able to be provided by WMR. The budget may only include a maximum of $20,000 of funding.Refer to pages 10-12 of the “WMR Research Support Program Guidelines” for a list of services/resources.

Milestone
Title / Support Service / Direct Funding Description (where applicable) / Project activity/s / Hours (where applicable) / $ Amount / Duration of milestone (months)
Milestone 1 Total / $
Milestone 2 Total / $
Milestone 3 Total / $
PROJECT TOTAL / $
Short Form / Date: 03/04/2017
Version: 2.0 / Page 1 of 7
  1. Consent to refer application

Do you consent to this application, supporting documentation and associated plication to be treated as Commercial-in-Confidence? / Yes / No
assessments being referred to external agencies for funding consideration?
  1. Ethics Application Details

The appropriate ethics approval MUST be obtained and sent to the Wesley Medical Research before the project can commence or any support provided.

Has this project already been submitted to the appropriate Ethics Committee/s?

YES  NO 

Indicate which Ethics Committee/s you have applied to or are applying to:

  1. Track Record of Investigators

Include a current CV (maximum 6 pages) with all previous research experience and/or a publication list (last 5 years only) of all Investigator/s.

  1. Signature

Chief Investigator

______Date: / /

Short Form / Date: 03/04/2017
Version: 2.0 / Page 1 of 7