Date:

HONORARY RESEARCHER APPLICATION FORM

This form is intended for use where an external institution wishes to conduct research which requires access to Western Health patients and/or their associated data by way of an honorary researcher appointment.

Please note that it is the responsibility of the hospital department in which the project is carried out to provide the honorary appointee with agreed resources, not the Office for Research. Each honorary appointee must have a Western Health Employee who is involved in the project act as their direct supervisor.

For further information, contact Mr Bill Karanatsios, Manager Office for Research on 83958073 or

NOTE: Honorary appointments may not always be granted, as theorganisationmay not have the appropriate resources.

Project Reference Number:

Project Title:

Brief Description of Project: (No more than 250 words)

  1. Name of proposed honorary appointee staff and associated duties to be carried out at Western Health:

Please attach a copy of each proposed honorary appointees full CV as required by WH People Services.

PERSONAL DETAILS
Title: / Given Name: / Surname:
Street Address:
Suburb: / State: / Postcode:
Home Phone number: / Mobile Number:
Email address:
Name of External Institution applicant is from:
Proposed Commencement date: / Proposed Completion date:
Will appointee be on site? / Yes No / If yes, which site/s?
Will appointee be working with Children (under 18)? / Yes* No *Provide Working with Children check.
Duties:
  1. Has ethics approval been granted for the project to be conducted at Western Health?

Yes / If yes, provide copy of ethics/governance approval certificate
No / If no, please give details of current review status of the project; give date of review, project reference if known and clarifythe reviewing institution below:
Western Health Low Risk Ethics Panel (low risk and QA projects)
Melbourne Health Office for Research / Other:
Review Date: / Project Reference number (if known):
  1. Who is the Western Health PrincipalInvestigator (PI)?

WESTERN HEALTH PI DETAILS:
Title: / Given Name: / Surname:
Will the Principal Investigator be the honorary staff direct supervisor? / Yes No
If not, please name which Western Health employee who will be and state their position on the research team:
Title: / Given Name: / Surname:
Position:
Contact number: / Email:
  1. Will any Western Health staff (other than the principal investigator) be required for this project?

Yes NoIf yes, please list number of staff, duties and approximate hours required:
Full Name of Staff / Department / Staff duties / Hours required

Attach separate list if required

  1. Please list all Western Health resources proposed to be utilised for the project:

(eg staff time, work space, computer usage, Western Health email access, stationary, storage space etc).

  1. Will resource use be reimbursed in anyway to Western Health?
  1. Please explain any intellectual property arrangements:
  1. Declarations

Honorary Researcher Appointee

I have read and agree to comply with the Western Health Researchers Code of Conduct (2012).

I also declare that all institutional safety standards and privacy policies will be adhered to during the conduct of the research at Western Health.

Name: / Signature: / Date:

Research Team Supervisor (PI or other applicable research team member as nominated in Section 3)

I declare on behalf of the research team that all publications resulting from this project will give appropriate acknowledgement to Western Health.

I also declare that all institutional safety standards and privacy policies will be adhered to during the conduct of the research at Western Health.

Name: / Signature: / Date:

Endorsed by: Western Health Department Director

(To be signed by the Department Director of the Principal Investigator)

Department Name:

I state that my department has the resources to accommodate the needs of this project and I support its conduct and the named applicant has the appropriate qualifications.

Name: / Signature: / Date:
MANDATORY- PLEASE PROVIDE (NOTE: Applications which do not include this information will not be processed)
Western Health Department Cost Centre For Police Check Fee:

Final Approval by: Director of Research/Delegate

I have reviewed this application and agree to the appointment of the named applicant.

Name: / Signature: / Date:
Checklist
Attached a copy of the HREC Approval certificate (If available)
Attached Full Curriculum Vitae of Honorary appointee
Provided Cost Centre details for Police check
Attached Fit2work Police Check Form – including certified identification documentation
Attached completed Offline Applicant Declaration Form

OP-HR2.1.3- Western Health Honorary Researcher Application Form August 2017Page 1 of 2