Office Use Only – Application Ref NIHR-CTF-2016-05-
NIHR CLINICAL TRIALS FELLOWSHIPS 2016ROUND 5 APPLICATION FORM
SECTION A – APPLICATION SUMMARY
Ai. Trainee Details
Surname / Forename / Title / ******DrMrMrsMissMs
Professional background please select from drop down lists / *****Medically QualifiedDentistNurse/MidwifeAllied Health ProfessionalOther Health ProfessionalNot a Health Professional
Medical Specialties: A – F / *****Acute Internal MedicineAllergyAnaestheticsAudio vestibular MedicineBroad Based TrainingCardiologyCardio-thoracic surgeryChemical PathologyChild & Adolescent PsychiatryClinical GeneticsClinical NeurophysiologyClinical OncologyClinical Pharmacology & TherapeuticsClinical RadiologyCommunity Sexual & Reproductive HealthDermatologyDiagnostic NeuropathologyEmergency MedicineEndocrinology & Diabetes MellitusForensic HistopathologyForensic Psychiatry
Medical Specialties: G – N / *****GastroenterologyGeneral (internal) MedicineGeneral PracticeGeneral PsychiatryGeneral SurgeryGenito-Urinary MedicineGeriatric MedicineHaematologyHistopathologyImmunologyInfectious DiseasesIntensive Care MedicineMedical MicrobiologyMedical Microbiology & VirologyMedical OncologyMedical OphthalmologyMedical PsychotherapyMedical VirologyNeurologyNeurosurgeryNuclear Medicine
Medical Specialties: O – Z / *****Obstetrics & GynaecologyOccupational MedicineOld Age PsychiatryOphthalmologyOral & Maxillo-facial SurgeryOtolaryngologyPaediatric & Perinatal PathologyPaediatric CardiologyPaediatric SurgeryPaediatricsPalliative MedicinePharmaceutical MedicinePlastic SurgeryPsychiatry of Learning DisabilityPublic Health MedicineRehabilitation MedicineRenal MedicineRespiratory MedicineRheumatologySport and Exercise MedicineTrauma & Orthopaedic SurgeryTropical MedicineUrologyVascular Surgery
Dental Specialties / *****Dental & Max-facial RadiologyDental Public HealthEndodonticsOral & Maxillofacial PathologyOral MedicineOral MicrobiologyOral SurgeryOrthodonticsPaediatric DentistryPeriodonticsProsthodonticsRestorative DentistrySpecial Care Dentistry
Nurse/Midwife / *****MidwiferyNursing
Allied Health Professional / *****Art TherapyDiagnostic RadiographyDieteticsDrama TherapyMusic TherapyOccupational TherapyOrthopticsOrthoticsParamedicsPhysiotherapyPodiatryProstheticsSpeech & Language TherapyTherapeutic Radiography
Other Healthcare Professionals / *****Clinical PsychologyComplimentary & Alternative MedicineHealth Care Scientist (Life Sciences/Pathology)Health Care Scientist (Physical Sci/Engineering)Health Care Scientist (Physiological Sciences)Health PsychologyPharmacyPsychological TherapyOther
if other please specify
Not a Health Professional / *****EpidemiologyFood ScienceHealth EconomicsHealth Services ResearchNutritionSocial ScienceSports ScienceStatisticsOtherNHS Management
if other please specify
Professional Body Registration If you are registered with the regulatory body or council of your profession please indicate which you are registered with
Which current NIHR training award do you hold? / ******NIHR Doctoral Research Fellowship (DRF)NIHR Post-Doctoral Research Fellowship (PDF)NIHR Career Development Fellowship (CDF)NIHR Clinical Lecturer (CL)NIHR Clinician Scientist AwardHEE/NIHR ICA Clinical Doctoral Research FellowshipHEE/NIHR ICA Clinical Lectureship (ICA CL) NIHR Clinical Academic Training (CAT) DRFNIHR Clinical Academic Training (CAT) CLNIHR Healthcare Scientist (HCS) DRFNIHR Healthcare Scientist (HCS) PDF
Proposed start date / ******01 Jan 201701 Feb 201701 Mar 201701 Apr 201701 May 201701 Jun 201701 Jul 201701 Aug 201701 Sep 201701 Oct 201701 Nov 201701 Dec 201701 Jan 201801 Feb 201801 Mar 2018
ORCID iD
Aii. Clinical Trials Unit Details
Clinical Trials Unit
Address 1 / Contact
Address 2 / Phone No
Address 3 / E-mail
Town/City
Address 5
Postcode
Current Appointment
Job Title
Department / Contact
Organisation
Address 1 / Phone No
Address 2 / E-mail
Address 3
Town/City
Address 5
Postcode
Proposed employer details if different from above
Department / Contact
Organisation
Address 1 / Phone No
Address 2 / E-mail
Address 3
Town/City
Address 5
Postcode
Correspondence address if different from above
Address 1 / Phone No
Address 2 / E-mail
Address 3
Town/City
Address 5
Postcode
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SECTION B – TRAINEE CURRICULUM VITAEEmployment History (most recent first)
Job Title / Institution / Start Date (dd/mm/yy) / End Date
(dd/mm/yy) / Full-time
or Part-time
*****Full-timePart-time
*****Full-timePart-time
*****Full-timePart-time
*****Full-timePart-time
*****Full-timePart-time
*****Full-timePart-time
*****Full-timePart-time
Qualifications
Three Highest Qualifications
*****PhD - UK instituteTaught or professional doctorate - UK instituteMD - UK instituteMasters (research) - UK instituteMasters (taught) - UK instituteOther postgraduate qualification - UK instituteOther postgraduate qualification - nonUK instituteFirst degree - UK instituteFirst degree - EU instituteFirst degree - other overseas instituteOther graduate equivalent qualificationProfessional qualificationHigher education qualification - less than degreeFoundation degreeOther non-advanced qualification
*****PhD - UK instituteTaught or professional doctorate - UK instituteMD - UK instituteMasters (research) - UK instituteMasters (taught) - UK instituteOther postgraduate qualification - UK instituteOther postgraduate qualification - nonUK instituteFirst degree - UK instituteFirst degree - EU instituteFirst degree - other overseas instituteOther graduate equivalent qualificationProfessional qualificationHigher education qualification - less than degreeFoundation degreeOther non-advanced qualification
*****PhD - UK instituteTaught or professional doctorate - UK instituteMD - UK instituteMasters (research) - UK instituteMasters (taught) - UK instituteOther postgraduate qualification - UK instituteOther postgraduate qualification - nonUK instituteFirst degree - UK instituteFirst degree - EU instituteFirst degree - other overseas instituteOther graduate equivalent qualificationProfessional qualificationHigher education qualification - less than degreeFoundation degreeOther non-advanced qualification
Professional Qualifications, Educational Qualifications, Degrees, Diplomas, etc.
Qualification / Class / Subject / Institution / Start Date (dd/mm/yy) / End Date (dd/mm/yy)
Awards and Grants held
Title of grant held / Role in Grant / Total Grant £ / Source of Grant (Organisation) / Duration (months) / Funding start date (dd/mm/yy)
Publications (please list most relevant/recent)
PART C – TRAINEE EXPERIENCE AND CASE FOR SUPPORT
Summary of experience
Overview of Training and Future Plans
Career Intentions
PART D – HOSTING ORGANISATION(S)
Contact details – Clinical Trials Unit
Surname / Forename / Title / ******ProfessorDrMrMrsMissMs
Address 1 / Contact
Address 2 / Phone No
Address 3 / E-mail
Town/City
Address 5
Postcode
Contact details – Employer if different from above
Surname / Forename / Title / ******ProfessorDrMrMrsMissMs
Address 1 / Contact
Address 2 / Phone No
Address 3 / E-mail
Town/City
Address 5
Postcode
CTU Proposed Training Programme
CTU Proposed Training Programme continued
Training Supervision
Surname / Forename / Title / ******ProfessorDrMrMrsMissMs
Surname / Forename / Title / ******ProfessorDrMrMrsMissMs
Surname / Forename / Title / ******ProfessorDrMrMrsMissMs
PART E – JUSTIFICATION OF RESOURCES REQUESTED
A1 - Applicant Salary Costs
A2 - Training and Development (maximum £5,000)
B1 – Estate Costs
B2 – Other Indirect Costs
PART F - DECLARATIONS AND SIGNATURES
Applicant
I confirm that I 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. / Yes / No
In Progress
I declare that, to the best of my knowledge, the information provided in this application is true, accurate and complete. I have read the terms and conditions of the NIHR Clinical Trials Fellwoships and, if my application is successful, agree to abide by them.
I undertake to conduct the research according to such guidelines for good research practice as the Host institution may from time to time lay down according to the NIHR research governance framework and the guidelines set out in ‘Good Clinical Practice in MRC-funded Trials’ (MRC 1998)
I agree that the NIHR may hold and process, by computer or otherwise, personal and other data supplied with this application and, if successful, additional data provided during the fellowship award.
Name (please print) / Signature / Date (dd/mm/yy)
NIHR Carbon Reduction Guidelines
Iconfirm that I have read the NIHR Carbon Reduction Guidelines and, where possible, taken steps to reduce the carbon emissions generated by this research.
Employer Organisation -Head of Department
As Head of Department of the host employing institution in which this award will be based, I approve this application and will support the candidate’s programme of activities as detailed in this application. The applicant is eligible for and capable of taking up this award. I confirm that the candidate will be eligible, for the duration of the award, to live and work in the UK.
Name:
Job Title:
Email Address:
Signature:
Date:(dd/mm/yy)
Employer Organisation -Research Contract Officer
As Research Contract Officer of the host employing institution, I have read the Guidance Notes and Contract for the NIHR Fellowship Scheme.
I confirm that the host institution would be willing to accept an award according to the terms and conditions of the NIHR Research Contract.
Name:
Job Title:
Email Address:
Signature:
Date:(dd/mm/yy)
Employer Organisation -Finance Officer
In signing this, you as the Administrative Authority or Finance Officer confirm that you have checked the financial details of this application Section 5.1 and the finance form and that the named employer is prepared to host this fellowship at the stated costs and to administer the award if made. You also confirm that the staff grade and salary quoted are correct and in accordance with the normal practice of this institution.
I certify that the figures provided are a true and accurate record of cost of the Fellowship according to the criteria included in the Fellowship Guidance Notes.
Name:
Job Title:
Email Address:
Signature:
Date:(dd/mm/yy)
Clinical Trials Unit Representative
As the Clinical Trials Unit representative of this proposed Fellowship, I approve this application and will support the candidate’s programme of activities as detailed in this application.
Name:
Job Title:
Email Address:
Signature:
Date:(dd/mm/yy)
PART Fi – CURRENT SUPERVISOR’S STATEMENT OF SUPPORT
Name
Job title
Signature
PART Fii – POST GRADUATE DEAN’S STATEMENT OF SUPPORT
Name
Signature
PART G – DEPARTMENT OF HEALTH MONITORING INFORMATION
How did you become aware of this Fellowship scheme? (NB: if from a colleague or advisor, it would also be helpful to know their source of information)
*****NIHR TCC WebsiteNIHR WebsiteWord of Mouth (colleagues or supervisor)Word of Mouth (current or previous award holder)Conference/Workshop/Presentation by NIHRAdvertisementInternet SearchDepartment/Institute/Affiliated InstituteOther / If ‘Other’ please give brief description below
UKCRC Health Categories - Select ONE or TWO Health categories
First category / *****BloodCancerCardiovascularCongenital Disorders and Chromosome DisordersEarEyeInfectious DiseasesInflammatory and Immune SystemInjuries and AccidentsMental HealthMetabolic and EndocrineMusculoskelatalNeurologicalOral, Gastrointestinal and Nutritional DisordersRenal and UrogenitalReproductive Health and ChildbirthRespiratorySkinStrokeGeneric Health RelevanceOther
Second (optional) category / *****BloodCancerCardiovascularCongenital Disorders and Chromosome DisordersEarEyeInfectious DiseasesInflammatory and Immune SystemInjuries and AccidentsMental HealthMetabolic and EndocrineMusculoskelatalNeurologicalOral, Gastrointestinal and Nutritional DisordersRenal and UrogenitalReproductive Health and ChildbirthRespiratorySkinStrokeGeneric Health RelevanceOther
UKCRC Research Activities - Only select ONE or TWO research activities – see guidance notes for details
Underpinning Research / Aetiology
1.1 Normal biological development and functioning / 2.1 Biological and endogenous factors
1.2 Psychological and socioeconomic processes / 2.2 Factors relating to physical environment
1.3 Chemical and physical sciences / 2.3 Psychological social and economic factors
1.4 Methodologies and measurements / 2.4 Surveillance and distribution
1.5 Resources and infrastructure (underpinning) / 2.5 Research design and methodologies (aetiology)
2.6 Resources and infrastructure (aetiology)
Prevention of Disease and Conditions and Promotion of Well-Being / Detection, Screening and Diagnosis
3.1 Primary prevention interventions to modify behaviours or promote well-being / 4.1 Discovery and preclinical testing of markers and technologies
3.2 Interventions to alter physical and biological environmental risks / 4.2 Evaluation of markers and technologies
3.3 Nutrition and chemoprevention / 4.3 Influences and impact
3.4 Vaccines / 4.4 Population screening
3.5 Resources and infrastructure (prevention) / 4.5 Resources and infrastructure (detection)
Development of Treatments and Therapeutic Interventions / Evaluation of Treatments and Therapeutic Interventions
5.1 Pharmaceuticals / 6.1 Pharmaceuticals
5.2 Cellular and gene therapies / 6.2 Cellular and gene therapies
5.3 Medical devices / 6.3 Medical devices
5.4 Surgery / 6.4 Surgery
5.5 Radiotherapy / 6.5 Radiotherapy
5.6 Psychological and behavioural / 6.6 Psychological and behavioural
5.7 Physical / 6.7 Physical
5.8 Complementary / 6.8 Complementary
5.9 Resources and infrastructure (development of treatments) / 6.9 Resources and infrastructure (development of treatments)
Management of Diseases and Conditions / Health and Social Care Services Research
7.1 Individual care needs / 8.1 Organisation and delivery of services
7.2 End of life care / 8.2 Health and welfare economics
7.3 Management and decision making / 8.3 Policy ethics and research governance
7.4 Resources and infrastructure (disease management) / 8.4 Research design and methodologies
8.5 Resources and infrastructure (disease management)
The Department of Health, National Institute for Health Research (DH NIHR) is the Data Controller under the Data Protection Act 1998 (‘the Act’). Applicants for funding should be aware that information contained in this application might be shared with other DH NIHR bodies for the purposes of statistical analysis and other DH NIHR management purposes, including targeted communications with selected groups of researchers. Applicants may be assured that DH NIHR is committed to protecting privacy and to processing all personal information in a manner that meets the requirements of the Act.
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