GSK Africa NCD Open Lab Early Career Scientists’ Preliminary Proposal form

Please download and save this form on your computer and then complete it by typing in your responses in the spaces provided insize 12Font. The completed form should then be submitted electronically as an attachment via the Idea Point submission portalby 4 pm on the 12th of January 2017.

Please read the GSK Open Lab call for proposals document carefully before proceeding with the completion of this application.

  1. Full name of applicant
  1. Applicant’s Education/Training

(List the most recent first)

Date (start and end :month/year) / Degrees and Diplomas (if applicable) / Course / University/Institution
  1. Previous posts: (list the most recent first)

Dates / Position held / University/Institution
  1. Further Training Plans

What is your area of specialty?
Please provide a brief description of the training pathway in your country for your specialist area.
Which stage of the training path are you currently at?
  1. Research Experience
  1. Publications

List up to 20 of your peer reviewed publications,including any “in press”, in chronological order, starting with the most recent first.

Please give citation in full, including title of paper or book chapter and list of all authors ensuring that your position as author is highlighted. Do not include abstracts)

  1. Presentations at scientific conferences

List up to 5 oral presentations or abstracts presented at scientific seminars/ conferences including the title, the date, venue and title of the conference and include abrief description of the audience.

  1. Research grants

List all research funding held (if any) in the last five years (most recent first). For current grants, please indicate the number of hours per week spent on activities related to that grant. Please leave blank if you have not held any grant in the past 5 years.

Project Title / Names of grant holders including your role / Awarding Body / Amount / Grant Period / Hours/week spent on grant
  1. Scientific achievements and mentoring and careerdevelopment plans (Provide a summary of up to tworesearch or academic achievements and your short, medium and long term research and career plans. Please indicate how this proposal will further your career. Please do not exceed 400 words)
  1. Research Project Proposal
  1. Title of Project
  1. Summary of Project

Provide a summary of the research, not more than 300 words. The summary should include a brief background and research question(s) or hypothesis, aims and objectives, research methods to be used and potential impact of the proposed research for practice and policy in Africa.

  1. Outline of research project (no more than 1500 words in total,excluding references. Graphs, figures and supporting data may be embedded in the text or included as an appendix or appendices. These additional data must not exceed the equivalent of 2 A4 pages in length )

Develop an outline of your proposed study giving a brief background to the project and any knowledge gaps identified, aims of the project, study design and methods to be used in investigating the problem and relevance of the project to the African setting. Please highlight statistical and ethical considerations as well as inclusion and exclusion criteria.

Scientific plan
References
  1. Potential for scaling up the research proposed

Please describe the potential for scaling up the proposed project and the follow-on plans including potential funding agencies to be considered for funding further research work (not more than 500 words)

  1. Outline Cost of the proposal in Pounds sterling

Amount in GBP
Materials and consumables
Equipment
Field work
Travel and subsistence
Research assistance
Training
Other
Total
  1. Justification of requested funds

Please provide the justification for the requested funds

  1. Where did you learn of this funding scheme? Please tick the most appropriate

Colleague
Personal contact
InstitutionalNoticeboard
Newspaper/Magazine (specify)
Journal (specify)
Conference/Workshop (specify)
GSK website
Other (specify)
  1. Are there any research and training gaps you have identified which you would be interested in addressing, should there be an opportunity to do so? □ Yes □ No

If yes, please specify 3 in order of priority (by indicating with number 1, 2, 3 in the table below)

Number / Number
Biostatistics / Genetics
Proposal writing & Grant application / Molecular Biology
Research Study Design / Clinical Trials
Grant management / Research ethics
Epidemiology / Other (please specify)
Writing for publication / Other (please specify)
  1. Local supervisor/mentor(s) supporting statement

(This part of the form should be completed by a senior academic or researcher who has agreed to provide supervision and mentorship to you during the duration of the project. The main supervisor/mentor must have a contract of employment in the academic/research institution of the applicant for the duration of the project. The supervisor/mentor must have a track record in research mentorship and training in any disease area, not limited to NCDs). An additional supervisor/mentor internal or external to your institution may also provide a supporting statement if considered to be necessary. Please duplicate this section if you have more than one supervisor/mentor.

Full name and Title
With whom do you have your current contract of employment?
Current position held
Address of institution
Email address
How long have you known the applicant and in what capacity?
How do you evaluate the merit of the proposed project and the applicant’s ability to complete the proposed work in two years?
Please give details of support, guidance or training that will be provided for the applicant and how this grant will advance the applicant’s career.
Please provide details of research students and fellows you have sponsored in the past five years (numbers sponsored, qualifications obtained and current employment status of students/researchers you have sponsored).
Can you confirm that the appropriate space and facilities will be made available to support the proposed project
  1. Institutions’ statement of support

Please submit your institution’s statement of support as a separate document. The letter should be printed on an official institutional letterhead. This can be completed by the head of your department, dean of faculty, principal of college or equivalent and should confirm that they support the application and if funded, the research and training will be supported with appropriate space and facilities and administered in the name of the organisation.The letter should also confirm if the applicant holds a salaried position.

Check List (to ensure that you are submitting all documents required for this application please tick the appropriate boxes below)

Yes / No
I have read the conditions for applicants and the call outline and I have met all the eligibility requirements
All sections of the application form have been completed
The section for mentor/supervisor has been completed
I have included my institutions’ letter of support

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