Health Professional Scholarship

Application Form

  1. Project Title

Simplified Project Title: / (100 characters max) / Research Category:
Scientific Project Title: / (300 characters max) / Click hereBiomedicalClinicalPublic HealthHealth Services
  1. Applicant Details

Title: / Click hereMsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone(include area code): / Mobile:
Current Institution: / Email:
Other Contact Details: / (Only complete if necessary, 100 characters max)
I am an Australian or New Zealand Citizen (attach a copy of your birth certificate or passport to Q27).
I am an Australian Permanent Resident (attach permanent resident certificate or evidence of submission for Australian Permanent Residency to Q27).
I am an Aboriginal or Torres Strait Islander Person.
  1. Administering Institution Details
Please ask permission before including other people’s personal information. The Privacy Statement at the end of this document should also be noted
Administering Institution: / Address:
ABN: / Suburb: / State: / Postcode:
Research Office :
RAO Contact Person: / Title: / Click hereMsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone: / Email:

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  1. Supervisor Details
    Please see our Privacy Statement at the end of this document

Title: / Click hereMsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Surname:
Telephone(include area code): / Mobile:
Email:
Position: / Current Institution:
  1. Project Synopsis and Potential Outcomes

Using lay terms, describe the overall aims of the research and expected cardiovascular health outcomes. Avoid technical terms. Your answer should be suitable for release to media and general publications.
(1500 characters maximum)
  1. Clearance Requirements

All ethics approvals and clearances necessary to complete the project outlined in this application must be forwarded to the Heart Foundation within 30 days of approval.
Select all EthicsRequirements Associated with your Research:
This project requires approval from a Human Research Ethics Committee
This project requires approval from an Animal Ethics Committee
This project requires approvals or exemptions relating to the genetic manipulation of organisms or the use of recombinant DNA, radioactive substances, potent teratogens, carcinogens or toxic chemicals?
If any of the approvals above are not required in order to commence the proposed work, please detail the reasons why and indicate the date when the ethics clearances will be required.
(800 characters maximum)

Application Details

  1. Health Professional ScholarshipStart Date

Nominated date of commencement: / Click here1st January 20171st April 20171st July 2017 / Nominated FTE: / Click here1.0 FTE0.9 FTE0.8 FTE0.7 FTE0.6 FTE0.5 FTE
  1. PhD Status

I have commenced my PhD / Commencement date: / dd / mm/yyyy / FTE to Date: / Click here1.0 FTE0.9 FTE0.8 FTE0.7 FTE0.6 FTE0.5 FTE0.4 FTE0.3 FTE0.2 FTE0.1 FTE
I have not commenced my PhD / Proposed commencement date: / dd / mm/yyyy
If you have completed the equivalent of more than 1 year of your PhD at 1.0 FTE at the closing date of application, you are ineligible to apply (e.g. 1 year @ 1.0 FTE = 2 years @ 0.5 FTE).
Other Status Details: / (Only complete if necessary, 400 characters max)
  1. Other Funding

Do you currently hold a PhD Scholarship? / Yes / No
If you do currently hold a PhD Scholarship, please provide brief details below including start and end dates of the scholarship as well as the scholarship name and provider.
(500 characters maximum)
Have you applied, or do you plan to apply, for a Scholarship to conduct similar research from any other funding body in 2016?
Funding Body: / Details:
Include award type, name, category and reference/application number if known

TRACK RECORD

  1. Summary of Qualifications
List your three most relevant qualifications.
Year / Qualification
(300 characters max) / Conferring Institution
(300 characters max)
yyyy
yyyy
yyyy
  1. Current Position

Position:
(300 characters max) / Institution:
(300 characters max) / Dates:
mm/yyyy-mm/yyyy
  1. Previous Positions
In order of most recent
Position:
(300 characters max) / Institution:
(300 characters max) / Dates:
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
  1. Awards & Achievements
List your top five awards or achievements.
Award / Achievement:(500 characters max) / Date:
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
  1. Cardiovascular Health Practice

Supply details of your track record in cardiovascular health practice. Please ensure that the relevance of your work to cardiovascular health is clear.
(1000 characters maximum)
  1. Research Involvement

Have you had any previous involvement in research? If so please briefly describe this involvement.
(1000 characters maximum)
  1. Motivation

Why do you wish to undertake a PhD at this time in your career? What are your overall career aspirations?
(1000 characters maximum)

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  1. Publications

Include only papers that have been published, or accepted for publication, in refereed journals (maximum 30). Do not include conference abstracts or submitted publications that have yet to be accepted. The list must be numbered and each reference should include: Title, Authors, Journal name, Year, Volume, Page Number. Please add impact factors and citations for each publication as well as the relative ranking or importance of each journal within its field (if available).
Published Papers
  1. Presentations

In the sections provided, please list invited, oral and poster presentations at conferences as well as other notable presentations (Maximum 30 across all four categories).
The list must be numbered and each reference should include: Title of presentation and the conference or event name, location and date.
Invited Presentations at Conferences
Oral Presentations at Conferences
Poster Presentations at Conferences
Other Presentations

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Purpose of Award

  1. Continued Cardiovascular Health Practice

How do you intend to continue your cardiovascular health practice during your PhD?
(2500 characters maximum)

Research Proposal

  1. Project Plan Summary

Provide a brief summary of your project plan.
(1000 characters maximum)
  1. Aims and Hypothesis

Summarise the Aims of your project and your Hypothesis.
(1000 characters maximum)
  1. Relevance to Cardiovascular Health

Indicate the relevance and impact of your project to cardiovascular health.
(1200 characters maximum)
  1. Research Environment

Provide details of facilities, infrastructure and funding that is available to support your proposed research activities.
(1000 characters maximum)

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  1. Research Plan and Figures

Research plans are limited to two pagesincluding this page (also including no more than 15 references) and must be completed using Arial 12 point font. Do not alter page layouts, borders, page or section breaks or any other formatting. Plans must start under this header. All documents not adhering to these guidelines will be reformatted and any additional information exceeding two pages will be automatically deleted. Documents significantly deviating from these guidelines will not be considered further.

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When preparing your research plan, please include Background, Methods and References sections (this sentence may be deleted).

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Referee Endorsements

  1. Referee 1
    Please see our Privacy Statement at the end of this document

Do not exceed this page
Referee Details
Title: / First Name: / Surname:
Telephone: / Mobile:
Email:
Position:
Institution:
What is your relationship to the applicant? (3 lines maximum)
Endorsement by Referee
I believe that the candidate is committed to cardiovascular health research and is capable of conducting the research outlined in this scholarship application while continuing their cardiovascular health practice. (no additional information required)
Signature: / Date:
__/__/2016
  1. Referee 2
    Please see our Privacy Statement at the end of this document

Do not exceed this page
Referee Details
Title: / First Name: / Surname:
Telephone: / Mobile:
Email:
Position:
Institution:
What is your relationship to the applicant? (3 lines maximum)
Endorsement by Referee
I believe that the candidate is committed to cardiovascular health research and is capable of conducting the research outlined in this scholarship application while continuing their cardiovascular health practice.(no additional information required)
Signature: / Date:
__/__/2016

Evidence of Citizenship

  1. Evidence of Citizenship

Insert evidence of citizenship, permanent residency (or application for permanent residency) below Two pages maximum including this page.

Insert here

Evidence of PhD Enrolment

  1. Evidence of PhD Enrolment

Insert evidence of PhD Enrolmentbelow. If you have yet to enrol in a PhD, a signed letter from your administering institution indicating that you are in the process of enrolling for a PhD should be inserted below. Two pages maximum including this page.

Insert here

Signatures

Applicant and Supervisor
I certify that all details provided in the Scholarship application (including annexures) are correct and that I have read, understood, and have abided by the instructions associated with this form.
I agree to carry out the project in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007).I acknowledge that all ethics approvals and clearances necessary to complete my project as outlined in this application will be in place before commencement of the work.
By signing, I confirm that I have complied with all instructions in the application form and understand that failure to do so may result in the withdrawal of the application from the review process.
I also acknowledge all supporting documentation has been provided with this application. I understand that my application will not be eligible for consideration by the Heart Foundation if this application is incomplete or lacking the required documents.
Please see our Privacy Statement at the end of this document
Applicant (full name): / Date:
Signature: / __/__/2016
Supervisor (full name): / Date:
Signature: / __/__/2016
Head of Department
I certify that appropriate facilities will be available to the applicant if successful and that I am prepared to have the project carried out in accordance with the Australian code for the Responsible Conduct of Research (2007).
Please see our Privacy Statement at the end of this document
Title: / First Name: / Surname:
Email: / Telephone:
Department: / Date:
Signature: / __/__/2016
Verification by Research Office
I, a representative of the Institution’s Research Office, verify that I have checked this application and that to the best of my knowledge, all instructions included in this form have been complied with and all relevant details are correct at the time of lodgement with the Heart Foundation. In addition, I verify that this institution has established administrative procedures for assuring sound scientific practice in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007).
Please see our Privacy Statement at the end of this document
Title: / First Name: / Surname:
Email: / Telephone:
Position:
Institution: / Date:
Signature: / __/__/2016

Privacy Statement

Your Personal Information is being collected by the Heart Foundation in order to assess your application for this grant. If you are not successful in your application we will retain your application on file indefinitely . We respect your privacy and embrace the principles contained in the Privacy Act. The Heart Foundation (we, us, our) is the National Heart Foundation of Australia and all associated Australian State and Territory Heart Foundation Divisions, full details of which can be found in our Privacy Notice.

If you do not want to receive further communication from us (other than information that relates to this application) or if you have any questions about privacy please contact the Research Program at or call (03) 9321 1581. Our APP privacy policy is set out in our Privacy Notice and details how you may complain about privacy issues and how we would deal with that complaint. It also explains how you can access, correct or update information we hold about you. A copy of our Privacy Notice is available at or on request. [HFPS06-140410-F]

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