Cochrane Fellowships Application Form 2015

Please complete in typescript and return by 4 June 2015 at 1pm.

1. Applicants Details
Name:
2. Current Work Details
Title/Position:
Department:
Address:
Tel Number:
Fax Number:
Email Address:
3. Home Address
Address:
Tel Number:
Fax Number:
Email Address:
4. Details of institution where review will be carried out and the Head of Department
Name:
Position/Title:
Address:
Tel Number:
Fax Number:
Email Address:
5. 300 Word Summary of the Review
Review Title:
6. Please give details of any preliminary or previous work carried out relevant to this application
7. Name of Cochrane Review Group (CRG)
Name:
7b. Please select the type of review you plan to undertake
Please tick / o  Cochrane healthcare intervention review
o  Cochrane methodology review
8. Has the Cochrane Review Group’s approval been obtained

Yes Please note: An electronic copy of the approval letter must be included with the application
Please give details of the CRG Editor who issued the approval letter
Name:
Position:
Tel Number:
Fax Number:
Email Address:
9. Details of Local Supervisor who has agreed to support the Fellow
Name:
Position:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
If the local supervisor is not based within the employing institution, please describe the arrangements envisaged for ongoing supervision over the term of the review.
What experience in conducting systematic reviews does your local supervisor have?
10. Details of contact editor nominated by the Cochrane Review Group, if applicable
Name:
Position:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
11. Details of other co-reviewers, if applicable
Name:
Department:
Institution:
What experience in conducting systematic reviews does the co-reviewer have?
12. Proposed Benefit
Please provide details of the proposed benefit that this Fellowship will have for the applicant and for the health and social care service and delivery on the island of Ireland or the proposed benefit to the methodology of research in health and social care (i.e., Cochrane Methodology Reviews).
13a. Please indicate how much time you intend to spend conducting the systematic review
Days/ Week:
Inclusive Dates
Start Date:
End Date:
Please indicate how you intend to spend your non-Fellowship time and manage the separation of your Fellowship and your work time
13b. Please provide a brief dissemination and Knowledge Transfer Plan for key stakeholders.
14. Finance
Current Grade:
Salary / Year 1 / Year 2 (if applicable)
Full Time / Pro-rata / Full Time / Pro-rata
Current Basic Grade Salary
Employers costs
(e.g. superannuation, national insurance PRSI)
Total:
Training and Travel
(e.g. Attendance at Relevant Courses / Travel to collaboration meetings) / Year 1 / Year 2 (if applicable)
Total:
(Max £2, 000 over duration of award)
c / Research Expenses(e.g. Photocopying, translation costs, Dissemination) / Year 1 / Year 2 (if applicable)
Total:
(Max £1,500 over
duration of award)
Overall total:
*For each of the items listed please provide justification below
15. Please give details of 2 referees who may be contacted to establish your suitability for this Fellowship
Referee 1
Position:
Department:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
Referee 2
Position:
Department:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
Cochrane Fellowship Application Form 2015
Name of Applicant:
16. Declarations
Applicant / “I have read ‘Guidance for Applications for Cochrane Fellowships’ and agree to abide by the conditions under which a Cochrane Fellowship is awarded. I declare that all the information provided in this application form is correct”.
Print: ______
Signature: ______
Date: ______
Local Supervisor / “I approve this application and am willing to supervise/ mentor the Fellow as required”
Print:______
Signature: ______
Date:______
“I have read this application and am willing to support the conduct of this review in my institution, if successful”. / Head of Department / Current Employer
(If Different)
Name:
Position:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
Print
Signature
Date

Please note that a hard copy of the declarations page of the application form, with original signatures, must be submitted to HSC R&D Division by 4 June 2015 at 1pm.

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