MEMBERSHIP APPLICATION FORM 2016
I would like to apply for the following membership:
Research Professional / ☐ / Comprehensive Student / ☐ / Associate Research Professional / ☐ /Affiliate Research / ☐ / Affiliate Student / ☐ / Collaborative / ☐ /
Education Professional / ☐ / Research and Education Support / ☐ /
Name / Research ID number *
Unit / Department
Supervisor (If applicable)
Academic affiliation
Other affiliation/s
Contact Details:
Address
Telephone / Email / Mobile
Please select a Theme and a Discovery pathway (D’s) and a Strength/Centre/Group/Unit in which your research best aligns. For further details refer to the research matrix within the membership guidelines.
Research Areas / Themes / Healthy Start to Life / ☐ / Combating Chronic Disease / ☐ /
Acute & Critical Care / ☐ / Healthy Ageing / ☐ /
D’s / Discovery☐ / Develop☐ / Deliver☐ / Disseminate☐
Strengths / Cancer & Palliative Care / ☐ / Perinatal and Maternal Health / ☐ /
Bone & Joint / ☐ / Rehabilitation & Ageing / ☐ / Pain & Neuroscience / ☐ /
Centre/Group/Unit
Please select an association category that best describes your role within the Kolling Institute
☐
KI Senior Research Leader (Centre or Department Head) / ☐
KI Postdoctoral researcher (university academic staff to Level B Step 3, or hospital scientist up to Senior Hospital Scientist Level 3)Mid- Career researcher (> 10 years post PhD). Year PhD conferred ______
☐KI PhD student - please also indicate below: / ☐
KI Postdoctoral researcher (university academic staff to Level B Step 3, or hospital scientist up to Senior Hospital Scientist Level 3)Early- Career researcher (< 10 years post PhD). Year PhD conferred ______
enrolled through Kolling Institute☐ / enrolled through other school/faculty☐
☐
KI Research Assistant/Technical Officer (University or NSLHD employed) / ☐
Research manager or clinical research coordinator (university or NSLHD employed) ______(please include title)
We, the undersigned, have read and understood the NSW Health Code of Conduct and policy directive Research- Ethical and Scientific Review of Human Research in NSW Public Health Organisation
Signatures / Applicant / Date
Director, Kolling Institute/ Chair, SRP&D Committee / Date
*Researcher ID Number is a unique identification number used by online resources to group together a particular author's work despite the variations required in author name format for different journals. If you do not have an ID Number please contact the Research Office for assistance.
Declaration of Interests
☐I am an employee of the Northern Sydney Local Health District
This declaration has been developed for documenting the employment arrangements for biomedical and clinical research leaders working within the Kolling Institute. As stated in NSW Health 'Code of Conduct' NSLHD employees agree to work in a professional and acceptable standard. The Code of Conduct is available via the above link. All Kolling Institute researchers employed by NSLHD agree to seek approval from the Chief Executive or his/her delegate for any secondary employment and any part time employees agree to seek approval for any secondary employment if there is a potential for a conflict of interest. Furthermore, all Kolling Institute researchers agree to conduct investigations in an ethical and fair manner, as described in the policy directive- Research- Ethical and Scientific Review of Human Research in NSW Public Health Organisations, and will report any conflict of interest matters to the Ethics & Governance Manager.
☐I am an employee or title holder of the University of Sydney
This declaration has been developed for documenting the employment arrangements for biomedical and clinical research leaders working within the Kolling Institute as employees of the University of Sydney. As stated in University of Sydney 'Code of Conduct': this Code has been formulated to provide a clear statement of the University’s expectations of its staff and affiliates in respect of their professional and personal conduct. The Code reflects, and is intended both to advance the object of the University, namely the promotion of scholarship, research, free inquiry, the interaction of research and teaching, and academic excellence, as well as to secure the observance of its values of:
• responsibility and service through leadership in the community;
• quality and sustainability in meeting the needs of the University’s stakeholders;
• merit, equity and diversity in our student body;
• integrity, professionalism and collegiality in our staff; and
• lifelong relationship and friendship with our alumni.
These values must inform the conduct of staff and affiliates in upholding and advancing:
• freedom to pursue critical and open inquiry in a responsible manner;
• recognition of the importance of ideas and ideals;
• tolerance, honesty, respect, and ethical behaviour; and
• understanding the needs of those we serve.
The complete Code of Conduct can be obtained from the University of Sydney website:
☐I am a student of the University of Sydney
Code of Conduct has been formulated to provide a clear statement of the University’s expectations of students in respect of academic matters and personal behaviour. Study at the University presents opportunities for interacting with other members of the University community. The University recognises and values the diversity of student experiences and expectations, and is committed to treating students, both academically and personally, in a fair and transparent manner. All students, in return, are required to comply with the requirements set down in the Code of Conduct for student. The full document of the Code of Conduct for students is available: The University reaffirms its commitment to:
• high academic standards, intellectual rigour and a high quality education;
• intellectual freedom and social responsibility;
• recognition of the importance of ideas and the pursuit of critical and open inquiry;
• tolerance, honesty and respect as the hallmarks of relationships throughout the University community; and
• high standards of ethical behaviour.
All students are required to be aware of and act consistently with these values.
We, the undersigned, have read and understood the NSW Health Code of Conduct, University of Sydney Code of Conduct for Staff and/or University of Sydney Code of Conduct for Students, as appropriate, and the policy directive Research- Ethical and Scientific Review of Human Research in NSW Public Health Organisation and agree to comply with all rules and regulations described.
Applicant ______Date______
Please submit 1 electronic and 1 hard copy of this form with a copy of your letter of employment or evidence of student enrolment to Michelle Moeskops,
Research Development Manager, Level 13 Kolling Building, Royal North Shore Hospital, St Leonards NSW 2065 Email: