NAME OF CANDIDATE: Page 1 of 30

THE CORE – DEREK BUTLER
FELLOWSHIP APPLICATION /
PART A: PERSONAL INFORMATION

Please submit your completed application to and a wet-signed copy to Research Awards, Core, 3 St Andrew’s Place, London, NW1 4LB by 5pm on 16th December 2016. Both the electronic and wet-signed hard copies are required for the application to be considered complete. The electronic file copy should be in Word and less than 3mb in size. Faxed, late or incomplete applications will not be accepted. Proof of postage will not be accepted as evidence of receipt by Core. Please readthe guidance notes before completing this form.

A1Personal Information
Title / First Names / Surname
Gender / Male Female / Date of Birth (dd/mm/yyyy)
A2Contact Details
Applicant
Correspondence Address
Telephone
E-mail
Supervisor
Name
Correspondence Address
Telephone
E-mail
Finance Officer
Name
Correspondence Address
Telephone
E-mail
Administrator for Fellowship (if not finance officer)
Name
Correspondence Address
Telephone
E-mail
PART B: APPLICATION DETAILS

B1 Application Details

Title / Forename / Surname
Applicant
Proposed Location
(Department and Institution)
Title / Forename / Surname
Applicant’s Proposed Head of Department
Department and Institution
Title / Forename / Surname
Proposed Sponsor
Department and Institution
Proposed Supervisor (1)
Department and Institution
Proposed Supervisor (2)
Department and Institution
Proposed Start Date
(Please indicate a realistic start date) / Proposed Duration
(in months)
Have you obtained approval from your Deanery to commence a period of research? / YES NO NA
If NO when will you obtain approval?
B2 Title of Study (Up to a maximum of 220 characters (in mixed case) including spaces and punctuation. Symbols and Greek characters must be spelt out in full).
B3 About the Applicant
Academic and higher professional qualifications(starting with most recent).
Academic Institution / Qualification / Class / Subject / Year of Award
B4Prizes Obtained Please describe prizes obtained and year of award.
B5Full Employment History, including present position
Include end date for current contract. List should start with current post and read in reverse chronological order.
*If you currently hold an academic post you must enter the end date of your contract in this box.
Department/Institution / Post Held
(including source of funding for research appointments) / From
(dd/mm/yy) / To *
(dd/mm/yy)
B6 If you have experienced any career breaks please detail below.
B7 Career Intentions – In what way would this fellowship further your career?
B8 Professional Body Membership (e.g. Royal Colleges, scientific societies, professional organisations).
B9 Publications(See guidance notes before completing) List any papers in refereed journals. Include title, all authors, journal and pagination. Please indicate with * the most significant publications.
B10 Research Experience to Date (including other relevant experience e.g. details of research training, technical skills, responsibility for managing other staff where applicable.)
B11Formal Research Training Courses to Date (Please copy and paste this section should you have more than one course.)
Title of course/modules
Location
Duration
Please specify whether: / Examined Formally assessed Not assessed Other
If other please specify
PART C: ABOUT THE PROJECT
C1 Abstract of Research (Up to a maximum of 400 words, please detail the aims, objectives, design, methodology, scientific and medical opportunities of the study.)
C2 Keywords (Up to a maximum of six keywords which are helpful in classifying research).
C3 Lay Summary (Up to a maximum of 400 words, explain to a lay audience the nature of the proposed research, the prospective outcomes and the potential impact of the research).
C4 Details of Research ProjectInclude (a) aims of the project, (b) work by applicants and others, which has led up to the project, (c) hypothesis and proof of concept, (d) experimental design, (e) methods to be used including statistical analysis and power calculations, (f) feasibility including an estimate of the likelihood of generating clinically applicable results within 5-10 years. (See guidance notes for more details).
Maximum 4 pages, excluding references.
C5 References Please give citation in full including title of paper, all authors and the first and last page numbers. Please put applicants name in bold where relevant. (See guidance notes for more details.)
Maximum 30 references.

PART D: CLINICAL DETAILS

This section is for medically qualified applicants only.

D1

What clinical contract do you currently hold?
Name of Health Authority or Hospital Trust
Date current contract expires
Please state your intended clinical specialty, if known
What progress, if any, has been made towards accreditation in your chosen specialty?

D2

Do you hold a CCST? / YES NO
If YES: state date awarded.
If NO: what date do you expect to qualify to receive it, if awarded this fellowship? (mm/yy)
What is your specialty according to the Department of Health list of recognised specialties?
What is your intended final specialty on completion of clinical training?
What level of honorary clinical contract will be sought during this award?
D2.1 Please state the clinical duties that are essential for the proposed research and the time required each week to perform these duties.
Please state what clinical duties are essential for the minimum requirements for higher training in your specialty, and how you intend to meet them.
Please state the total time you intend to spend each week on clinical work, including the two questions above.
PART E: SPECIFIC CONSIDERATIONS
E1Human Research
Does the research proposed raise ethical issues?(MANDATORY) / YesNo
If YES please state what these ethical issues are below:
E1.1 Does your research involve:
  • Experimentation on human participants (including volunteers?)
/ YesNo
  • The use of human tissue?
/ YesNo
  • The use of biological samples?
/ YesNo
If your answer to any of the above is YES, justify your use of human participants and the numbers involved and/or the nature and quantity of human material to be used.
If human participants (including volunteers) are being used, are there equal numbers of males to females? / YesNo
Does the research involve the administration of drugs, chemical agents of vaccines to humans? / YesNo
Any other factors, please detail below:
E1.2 Does the research involve the use of personal information? / YesNo
If YES is the information:
(Please select only ONE of the following)
Identifiable / Anonymised Linked
Coded / Anonymised Unlinked
E1.3 Approval from relevant research ethics committee:
Given / Not Given
Pending / N/A
If pending please state when you applied and when an outcome is expected
E1.4 Have necessary approvals been given by:
The Gene Therapy Advisory Committee / YesNoNA
The UK Xenotransplantation Interim Regulatory Authority / YesNoNA
Administration of Radioactive Substances Advisory Committee (ARSAC) / YesNoNA
Other Bodies as appropriate? Please detail below:
E1.5 Are there any other factors that Core should be aware of? Please detail below:
E2 Animal Research
Do your proposals include the use of animals or animal tissue? / Yes No
If YES: do your proposals include procedures to be carried out on animals in the UK which requirea Home Office Licence? / Yes No
If YES: has the Home Secretary granted a Project Licence, under the terms of the Animals (Scientific Procedures) Act 1986, authorising the proposed experiments? / Yes No
If YES: state the name of the licensee, the project licence reference number, date of issue and end date.
Do you, or any other researchers associated with the project, hold a Personal Licence under the Animals (Scientific Procedures) Act 1986, permitting the procedures required for the research to be carried out? / Yes No
If YES: give Personal Licence Reference Number and the name of the Licence Holder.
If NO: has application been made for such a licence? / Yes No
E2.1 Do your proposals include the use of animals or animal tissue outside the UK? / Yes No
If YES: give details of the local ethics committee approval that has been sought, relating this approval to the permission which would be required if the research were to be conducted in the UK.
E3Licences and Approval
I confirm that I will have secured all necessary licences and ethical approvals in relation to the research and will abide by the terms of those licences and approvals in carrying out the research by the take up of the fellowship. / YesNoNA
PART F: OTHER FORMS OF SUPPORT
F1 Previous Core applications (Provide details of previous grants or fellowships funded by Core as well as unsuccessful applications).
1st Application / 2nd Application
Type of Fellowship/Grant
Title of Project
Award Made (Y/N)
Start Date
End Date
Amount Sought/Awarded (£)
F2 Submission Elsewhere (Is this or a related application currently being submitted elsewhere?)
1st Application / 2nd Application
Type of funding
Awarding Organisation
Title of Project
Expected Decision Date
Amount Sought/Awarded (£)
PART G: FINANCIAL INFORMATION

(Please consult guidance notes before completing)

Please note that Core does not fund equipment costs (including computer hardware, software and maintenance costs).

G1Research Costs
Year 1 / Year 2 / Year 3 / TOTAL
a) Materials and Consumables
(please give brief description)
SUB TOTAL
b) Animals (see question G4)
Total purchase price: p.a.
Total maintenance cost:
Total procedure cost:
SUB TOTAL
c) Miscellaneous (including publication costs and travel, registration and other related expenses for conferences – see guidance notes)
SUB TOTAL
G2 Salary Costs
Year 1 / Year 2 / Year 3
Salary
NI and Superannuation
SUB TOTAL
G3 Total
TOTAL GRANT REQUESTED / £
G4Breakdown of Animal Costs
(a) Animals species
Indicate species of animal used:
(b) Purchase / Year 1 / Year 2 / Year 3
Number to be purchased per annum
Source of supply and biological quality
Purchase price per animal
(c) Maintenance / Year 1 / Year 2 / Year 3
Number of animals to be maintained
Number of weeks’ maintenance required
Cost per animal per week
(d) Experimental procedures
Types of procedure
Cost per procedure

NAME OF CANDIDATE: Page 1 of 30

G5Justification for Support (Mandatory)
Please see guidance notes for information on what to include in your justification
Justify why support is necessary, resources and consumables requested, including animals, in terms of scientific need. Maximum 1 page.

PART H: OTHER QUESTIONS

H1 Candidates proposing to work abroad for part of their fellowship
Period of time to be spent abroad with dates (maximum 6 months)
Name and address of overseas institution
Name of sponsor/supervisor in overseas institution
Position
H2 Conflicting interests: consultancies and equities
Do any of the applicants or supervisors/sponsors have consultancies or any equity holdings in companies or other organisations that might have an interest in the results of the proposed research? / YES NO
If YES give brief details
H3 Commercial Exploitation
Will the proposed research use technology, materials or other inventions that, as far as you are aware, are subject to any patents or other form of intellectual property protection? / YES NO
If YES give brief details
H3.1 Is the proposed research in whole or in part, subject to any agreements with commercial academic or other organisations? / YES NO
If YES give brief details
H3.2 Is the proposed research likely to lead to any patentable or commercially exploitable results? / YES NO
If YES give details
H3.3 If any potentially commercially exploitable results may be based upon tissues or samples derived from human participants; please confirm that there has been appropriate informed consent for such use. / YES NO NA
Give details if necessary
PART I: DECLARATION AND SIGNATORIES

In submitting this research proposal, we confirm that:

APPLICANT
  • If a fellowship award is offered and accepted, I will abide by Core’s Terms and Conditions of Research Fellowships and any subsequent amendments.
  • I have not entered into any obligations which would conflict with Core’s Terms and Conditions of Research Fellowships.

Signature of applicant: Date:
Name:
HEAD OF DEPARTMENT
  • If the fellowship is awarded and accepted the work will be accommodated and administered in the department/institution in accordance with Core’s Terms and Conditions of Research Fellowships and any subsequent amendments.
  • If the fellowship is awarded and accepted, I will ensure that the applicants abide by Core’s Terms and Conditions of Research Fellowships and any subsequent amendments.
  • If the fellowship is awarded and accepted, I agree that the resources provided by Core under the fellowship shall be applied for the purposes of the research approved under the fellowship only.

Signature of Head of Department: Date:
Name:
UNIVERSITY RESEARCH GRANTS/FINANCE OFFICER
  • If the fellowship is awarded and accepted the candidate will be offered an appointment, subject to the University’s normal employment practices, for the full tenure of the Fellowship.
  • If the fellowship is awarded and accepted the University will abide by Core’s Terms and Conditions of Research Fellowships and any subsequent amendments. It will also ensure that all institutes hosting research supported through this fellowship abide by Core’s Terms and Conditions of Research Fellowships and any subsequent amendments.
  • The staff grading and salaries quoted are correct and in accordance with the normal practice of this institution.

Signature of Administering Authority: Date:
Name:

Personal and other data on Core fellowship applications will be stored by Core to aid the internal processing of applications. Core may make public in any form summary information about the application as it may see fit. Should the application be successful Core may publish the name, work address and contact details, including email address, and summary information about the award including the title, abstract of research and value on Core’s website or in its annual report or other publications from time to time. Information may also be made available to external bodies.

PART J: SUPPORTING STATEMENT OF PROPOSED SUPERVISOR
J1Applicant’s name
Title / Initials / Surname
J2Supervisor
Supervisors’ Names
Summary of Training and Skills Provided Please consult guidance notes before completing.
Maximum 2 pages.
Summary of Training and Skills Provided (continued)
Maximum 2 pages.
J3Relationship of current application to other work in the supervisor’s department.
(See guidance notes.)
J4Candidate’s contribution to this project
Has the candidate worked on the pilot project (if any) / YES NO
How much has the candidate contributed towards devising and writing this application form?
J5 About the Proposed Department
Number of academic staff in the department
Department’s rating in the most recent HEFCE Research Assessment Exercise:
J6Supervisor’s Curriculum Vitae
Please duplicate for each Supervisor.
Supervisor’s Name:
Degrees:
Present Post (with dates):
Last three posts held (with dates):
J6.1 Supervisor’s Current Grants

Number of Research Grants

Approximate grant income last financial year

/ £
J6.2 Supervision of Fellows/PhD students and Source of Funding

How many Fellows/PhD students have you supervised in the past?

How many Fellows/PhD students are you supervising currently?

How many are you likely to be supervising at the same time as the proposed project?

How many fellows/PhD students were:

iawarded an MD.

iiawarded a PhD within 4 years.

iiiawarded a PhD within 5 years.

ivfailed to complete within 6 years.
J6.3Supervisor’s Publications
Provide details of any recent papers over the last 5 years in refereed journals. Include title, authors, journal and pagination. Please indicate with a * the most significant publications. (See guidance notes.) Maximum 1 page.
J6.4State your views on the applicant’s scientific ability and suitability for further research training.
Please provide a summary addressing each of the following issues:
  • comment on the candidate and their suitability for a Core Fellowship
  • suitability of the project for the research training and career development of the candidate
  • why the centre is appropriate for the work proposed.
Maximum 1 page
PART K: DECLARATION AND SIGNATORIES FOR TRAINING COMMITMENT SUPERVISORS ONLY

Training contract

In the event of Core making an award to the above named fellowship applicant, under my supervision at the department and institution identified in the application, I/we as the named supervisor(s) agree to provide high quality research training opportunities for the fellow in terms of:

Training Programme
  • A research project that is achievable in the proposed duration, is well structured, provides an intellectual challenge and provides opportunities for comprehensive research training.

  • Comprehensive training in subject-specific research skills (either at the bench or more formally through taught courses).

  • Training in generic research skills e.g. experimental design, data handling, statistics.

  • Training in transferable skills required for a research career e.g. oral and written communication, time management.

  • Opportunities to present research results to peers, colleagues and, when appropriate, expert scientific groups.

Training Environment
  • Exposure to high quality science in an intellectually stimulating and active research environment/research team.

  • Opportunities to mix with other trainees and post-doctoral researchers working in related topics both within the department and outside.

  • Access to appropriate facilities and equipment, and comprehensive technical training

Standards of Supervision
  • Regular access to myself, or a second supervisor (with appropriate skills and experience) as nominated by me.

  • Regular monitoring of the fellow’s planning, research progress and skill development.

  • Regular feedback on performance.

  • Access to timely career advice.

Financial Arrangements
  • The awarded monies will be made available to directly support the fellow’s research training.

Notification of Changes
  • Core’s authority will be sought, in advance, for any changes to a fellowship during its tenure e.g. transfer to another institution, temporary absence of supervisor(s), change of supervisor(s).

  • Core will be provided with early notification of any problems associated with the fellow’s project or progress.

In addition, I confirm that this Core fellowship will be accommodated and administered in accordance with Core’s Terms and Conditions of Research Fellowships and any subsequent amendments.
Signed (Supervisor 1): / Date:
Name:
Signed (Supervisor 2): / Date:
Name:

PART L:COLLABORATION ON A GRANT

Collaborators, i.e. scientific/medical colleagues, who are associated with a research proposal and named in the body of the application, are asked to complete this form and return it to the candidate or sponsor.