HRC-CDA Form

HRC Ref ID#: nm/xyzNI: NI Surname

HRC REF #

Career Development Award Application Form (HRC-PacificHMA)

Applicants are advised to:

1) read the Guidelines for definitions and instructions before completing this form;

2) read the HRC Rules for applicant eligibility criteria and budgetary entitlements;

3) confirm the application due date for hardcopies and electronic files;

HRC Ref ID#:Click here to enter text.

Applicant:Click here to enter text.

This COVERSHEET is for identification purposes. It will be replaced by the online pages (Module 1, Section 1A) in the final submitted application compiled by the HRC Gateway (

Information can only be entered into the fields indicated. Enter the details above before going to page 2.

When completed, save this form as a pdf file before uploading to Gateway. In the pdf version of this document, Section 1B must begin on page 2.

Due date for online submission is 2 September 2014. Hard copy delivered to HRC by 4 September 2014. Late applications will not be accepted. The information contained in this application form must be full and correct, or it will be rejected.

Indicate type of computer used to complete this form (X): Windows PC: or, MAC:

Enter the HRC Ref # in the box at the top left of this page.

In thesecond pageheader, replace “nm/xyz” with your application HRC Ref #; replace “NI surname” with your surname.

MODULE 1: APPLICANT

Section 1B: Personal Information

Pacific affiliation/s
Applicant mailing address if different from your address for correspondence.
Phone
Mobile
Email address
Employment
Do you intend to be employed during the tenure of this award[1]? / Yes/No
If “Yes”, please provide the following details:
Place of employment
Hours per week

Please note that if you are currently working and studying part time you may only receive part of the scholarship

Are you applying for a Preventing and Minimising Gambling Harm Career Development Award? / Yes/No

Section 1C: Career Plans

Briefly describe your background and potential; specifically, describe how the proposed award will support your career plans (1 page maximum)

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Section 1D: Academic Support

Research Supervisor(s)/academic support/cultural advisor(s)
Title, first name, surname / Role / Institution/Organisation

Reasons for selection of those listed above

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Section 1E: NZ MSI Standard CV – Applicant

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PART 1

1a. Personal details of Applicant
Full name / Title / First name / Second name(s) / Family name
Present position
Organisation/Employer
Contact Address
Postcode
Work telephone / Mobile
Email
Personal website (if applicable)
1b. Academic qualifications

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1c. Professional positions held

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1d. Present research/professional speciality

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1e. Total years research experience
1f. Professional distinctions and memberships (including honours, prizes, scholarships, boards or governance roles, etc)

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1g. Total number of peer reviewed publications and patents / Journal articles / Books, book chapters, books edited / Conference proceedings / Patents

PART 2

2a. Research publications and dissemination history
Peer-reviewed journal articles
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Peer reviewed books, book chapters, books edited (SELECTED)
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Refereed conference proceedings
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Patents
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Other forms of dissemination (reports for clients, technical reports, popular press, etc)
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Please list any other awards/publications deemed relevant to your research (half a page maximum).

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Section 1F: Applicant Academic Transcript

Please provide a witnessed signed copy of your academic transcript and insert after this page.

MODULE 2: RESEARCH INFORMATION

Overview of Proposed Research

Use the space below (8-page limit) to describe the research.

The research description should include:

A description of the applicant's field of research interest and an overview of research or work previously undertaken by the applicant.
A summary of the proposed research, structured under the following headings:

Please note that the Aims and Objectives, Timelines and Key Milestones will be used to form the basis of the contract if the application is successful.

The Preventing and Minimising Gambling Harm Scholarship is very specific in addressing the prevention and minimisation of gambling harm, your proposal including the information under following headings must reflect this. (see explanatory notes).

Aims and objectives
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Timelines (use Gantt chart)
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Key milestones
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Pacific Health significance
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Research design and methods
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Dissemination of results
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An indication of Pacific community and/or community support for the research (if relevant)
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MODULE 3: REFERENCES

Please use the one-page limit only

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MODULE 4: BUDGET AND CONTRACT INFORMATION

4A: Budget costs

Item / Cost

Section 4B – Contract Information

Host Institution[2]

Has the Host Institution/Organisation committed to support this research?

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Section 4C – Previous / Current Contracts and Awards

List Previous / Current Contracts awarded within the past 5 years. Final HRC reports may be made available to Science Assessing Committees.

Copy and paste additional tables if required.

Funding agency
Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #), was Final Report filed? If not, why?
Funding agency
Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #), was Final Report filed? If not, why?

Section 4D – Other Support

Other Research Applications Awaiting Decision

Applicants must advise the HRC of the outcome of other research applications through their Research Office.

Please outline any other application awaiting decision

Funding agency
Total value
Date of outcome
Funding agency
Total value
Date of outcome

Section 4E – Letters of Collaboration/Supporting Documents List

Please identify agencies/communities etc that have provided any support letters to accompany this application. (include all documentation with this application).

MODULE 5: NZ MSI STANDARD CV – Supervisor(s)

This information will be used to assess the suitability and expertise of your supervisor/research team in the field of research you intend to undertake. Provide a CV for each individual if applicable.

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PART 1

1a. Personal details of Supervisor/Investigator
Full name / Title / First name / Second name(s) / Family name
Present position
Organisation/Employer
Contact Address
Postcode
Work telephone / Mobile
Email
Personal website (if applicable)
1b. Academic qualifications

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1c. Professional positions held

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1d. Present research/professional speciality

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1e. Total years research experience
1f. Professional distinctions and memberships (including honours, prizes, scholarships, boards or governance roles, etc)

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1g. Total number of peer reviewed publications and patents / Journal articles / Books, book chapters, books edited / Conference proceedings / Patents

PART 2

Please list any other awards/publications deemed relevant to your research (half a page maximum).

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MODULE 6: ADMINISTRATION

This Module will only be required from successful applicants offered a contract. It is provided here for reference only. No signatures are required. The full administration agreement can be downloaded from the HRC website.

Section 6A – Ethical and Regulatory Agreement

The applicant has read the ‘Guidelines on Ethics in Health Research’ and ‘Te Ara Tika - Guidelines for Maori Research Ethics: A framework for researchers and ethics committee members,’ available from the HRC website, and agrees to abide by the principles outlined in them. The undersigned also agrees to provide written evidence before any research procedures commence, that in any study involving animal or human subjects, animal or human materials or personal information, a properly constituted accredited Ethics committee (a list of currently accredited Ethics Committees is available on the HRC website) has examined and agreed to the ethics of the proposal outlined in this proposal. If minor changes in the research design or procedures have been required for ethical reasons, the HRC must be informed of them. The undersigned also undertakes to ensure that all regulatory consents are gained before research commences. For further information regarding the ethical approval process, please contact the Secretary to the HRC Ethics Committee, , or the appropriate accredited Ethics Committee.

Section 6B – Administrative Agreement

All HRC applications must include an undertaking to abide by the following administrative agreement:

1.It is understood and agreed that this application and any contract awarded as a result of this application is subject to the Health Research Council of New Zealand Rules (“Permissible Use of Research Funding and Operation of Contracts”). Funds will not be expended for any other purpose than described in this application.

2.The host institution agrees and undertakes to bear all risk and claims connected with any operation covered by this application and to indemnify and hold harmless the Council against any and all liability suits, actions, demands, costs or fees on account of death, injuries to persons or property, or any other losses resulting from or connected with any act or omission performed in the course of the research.

3.The host institution agrees and undertakes to support for the duration of any contract, the work described in this application by making available accommodation, basic facilities for research and the services necessary for its fulfilment.

4.The Head of Department agrees to accept this research within his/her department if a contract is made, agrees to provide workload relief for research staff working on this contract (Principles of Full Cost Funding), and is aware that s/he may be requested by the HRC to provide a confidential assessment of the research during the term of the contract.

5.The host institution official designated below agrees to ensure that the research will have been approved, where necessary, by the appropriate institutional biosafety committee and/or all other required regulatory agencies before research is commenced.

6.The applicant(s) agrees to allow specified personal information to be used for statutory and publicity purposes.

7.The host institution has in place policies and processes to ensure that consultation with Māori has occurred and the application is responsive to the needs and diversity of Māori.

We the undersigned have read the above administrative agreement and undertake to abide by the conditions of this agreement in respect of any contract made by the Health Research Council of New Zealand as a result of this application. We the undersigned confirm that the information provided in this application is to the best of our knowledge true, that all sections are correct at the time of application submission, that each NI agrees to the stated FTE% contribution and that funding to any NI from any source will not exceed 100 FTE%.

MODULE 7: AUSTRALIAN AND NEW ZEALAND STANDARD RESEARCH CLASSIFICATION (ANZSRC)

This Module is for evaluation purposes and is mandatory; incomplete applications will not be processed.

Do not copy MODULE 7. Send with original application only.

Applicants are required to categorise their research using the ANZSRC codes for Socioeconomic Objective classifications found on the HRC weblink ( – find the appropriate 6-digit code(s) and description and insert below. Only provide 3 categories with % in increments of 10.

Research Descriptors
MSI Socioeconomic Objective (SEO) (6-digit code and description) / Weighting %
(increments of 10; totals to 100%)

MODULE 8: Supervisor Report and Unacceptable Reviewers

Section 8A – Supervisor Report

Name / Click here to enter text.
Email Address / Click here to enter text.
Area of Expertise / Click here to enter text.
Relationship to applicant (if any) / Click here to enter text.

Section 8B – Potential Reviewers Unacceptable to Applicant

An individual or research group may be unacceptable as reviewers because: 1) they are direct competitors, 2) there is a conflict of interest, 3) there are commercially sensitivity issues.

Name / Click here to enter text.
Organisation/Location / Click here to enter text.
Reason / Click here to enter text.
Name / Click here to enter text.
Organisation/Location / Click here to enter text.
Reason / Click here to enter text.

[1]A recipient may not hold other paid positions without permission from the HRC Board. Normally this permission will be given for teaching/clinical activities in support of the recipient’s professional development not exceeding 400 hours per year and with approval from their supervisor.

[2] The HRC expects that costs of the research undertaken by scholarship/fellowship recipients over and above that provided by the award will be borne by the host institution. Applicants should confirm that such resources are in place to ensure the successful completion of their award. Whilst it is the responsibility of the host institution to bear the cost of the research, this does not preclude the submission of a proposal in the HRC funding round. Applicants should understand that such funding is contestable and not guaranteed. The HRC’s contribution to research costs is intended to facilitate the establishment of the scholar/fellows research programme.