2017-18 Greenshoots Application Form

  1. Applicant Details
  1. Clinical Research Specialty Group

Please indicate all disciplines/ specialty interest areas for the studies to which you will be contributing.

/ Adult Oncology / / Reproductive Health / / Infectious Diseases and Microbiology
/ Paediatric Oncology / / Nervous System Disorders / / Anaesthesia, Peri-operative Management & Pain
/ Dementias & Neurodegeneration / / Hepatology
/ Cardiovascular / / Mental Health / / Critical Care
/ Renal / / Injuries and Emergencies
/ Metabolic and Endocrine / / Musculoskeletal Disorders / / Respiratory
/ Diabetes / / Primary Care / / Gastrointestinal
/ Oral and Dental / / ENT
/ Genetics / / Health Services & Research Delivery / / Surgery
/ Haematology / / Ageing / / Ophthalmology
/ Paediatrics / / Dermatology
  1. Involvement with known and potential NIHR CRN Portfolio studies

This question aims to assess the potential pipeline of studies available to your specialty. Please clearly cite NIHR CRN Portfolio studies that are currently open or have been open in the last 12 months, or those that will be open within the next 12 months that:

  • you have been involved with (mark as “I”)
  • have formally expressed an interest in (“EOI”)
  • any other potential studies that you could have expressed interest in if you had support (P)
  • if you are also carrying out any non-NIHR CRN Portfolio studies please list these indicating clearly that they are non-NIHR CRN Portfolio.

Comm-ercial
Y/N / NIHR CRN Portfolio ID/ Non-Portfolio *indicate / IRAS ID (if known) / Study Title / Proposed No. patients recruited/ target or actual / Sponsor / Involved (I)/ Expression of Interest (EOI)/ potential (P) *indicate
  1. Relationships and Activities

Please indicate any relevant internal / external relationships you have with commercial sponsors / partnership relationships e.g. Data Management / Trial Steering Committees, Consultancy including detail such as sponsor, nature and duration of the relationship as appropriate.

Please limit your response to 250 words.

  1. Infrastructure access

Please explain the infrastructure available to you within your own organisation, Specialty and /or across the network.

Please limit your response to 250 words.

  1. Patient Access

Please explain your access to relevant patient populations.

Please limit your response to 100 words

  1. Personal Statement

Please describe why you think you would make good use of this support.

Please limit your response to 100 words

  1. Enrolment for PGCertClinRes

I plan to enrol for the Postgraduate Certificate in Clinical Research at Newcastle University (2017-18)

Yes / No

  1. Approvals and Support
  1. Mentor

I confirm that I have secured indicative support from my proposed mentor with my application (email from mentor is acceptable)

  1. Time and Funding

I confirm that I have I have approval/support to be able to access the award and incorporate this into my existing job plan if successful (email from organisational Clinical Director is acceptable)

  1. R& D Director

This application must be approved by the R&D Director of the appropriate NHS Trust.

Applications which are not signed by an R&D Director will be rejected outright

Name of R&D Director:

Signature:

NB. FOR COMMERICAL APPLICATIONS ONLY

By signing this application form you are also confirming that match funding support for year 2 of the programme will be provided if this applicant is successful

Applicant Signature:

Date:

Applicants will be notified of outcome week commencing 9 January 2017and awards will commence 1 April 2017