Please Fill in Details Below for Return of Receipt Record

Please fill in details below for return of receipt record:

Address Label

NAME OF APPLICANT
INSTITUTION/AGENCY NAME
ADDRESS AND POSTCODE

HEALTH PROMOTION ABORIGINAL

RESEARCH TRAINING SCHOLARSHIP

APPLICATION RECEIPT RECORD

Please forward this application receipt record to Healthway along with your ORIGINAL PLUS 3 COPIES of your application for a Health Promotion Aboriginal Research Training Scholarship.

Please attach this application receipt record to your ORIGINAL COPY ONLY.

OFFICE USE ONLY: Your application for a Health Promotion Aboriginal Research Training Scholarship has been received at Healthway on / / 2015

SIGNED:

FILE NO:(to be quoted in all correspondence relating to your application)

POSTAL ADDRESSCOURIER ADDRESS

Health Promotion Research ProgramHealth Promotion Research Program

HealthwayHealthway – Ground Floor

PO Box 128424 Outram Street

WEST PERTH WA 6872WEST PERTH WA 6005

Tel: (08) 9476 7000 or 1800 198 450Fax: (08) 9324 1145

Email:

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HEALTHWAY ABORIGINAL RESEARCH TRAINING SCHOLARSHIP

OFFICE USE ONLY

IMPORTANT / File No:
Please submit an original and three copies with Curriculum vitae

SECTION A: PERSONAL DETAILS

1. Title: Mr/Ms/Mrs/Miss:______

2. Full name of applicant:______

3. Date of birth: ______

4. Home address: ______

5. Are you an Aboriginal or Torres Strait Islander resident of Western Australia? ☐ Yes ☐ No

6. Full address at your present institution and department:

______

______

Please circle preferred address for correspondence: Work Institution

7. Home telephone number: ______8. Work telephone number: ______

9. Mobile: ______10. Email if applicable: ______

Would you like Healthway’s eNews to be sent to this email address? Yes No

11. Present place of employment and position:

______

12. Date of appointment: (day/month/year):______

13: Is your position: Full-time  Part-time  Casual 

SECTION A (continued)

14. Are you applying for top-up funding? (refer to page 4 of the guidelines) Yes No 

If you have answered yes to Q14:

14a. Please state 1) the name of the award you have been offered or currently hold, 2) the name of the

funding body, the 3) duration of the award and 4) theamount funded for each year of the award

15. Are you applying for a: Student  or Professional  Stipend (tick one box only)

Only complete questions 16 to 19 if you are applying for a Professional Stipend (see guidelines)

16. Your current annual gross salary: (please state amount in Australian dollars before deductions): $___

17. Net payafter tax (please state amount in Australiandollars

and indicatefrequency of payment, eg, fortnightly, monthly): $______

18. Name of manager/supervisor:______

NB: All applications require a letter of support from the student’s primary supervisor.

19. Manager/supervisor’s telephone number:______

LATE APPLICATIONS WILL NOT BE ACCEPTED.

CLOSING DATE: 31JULY 2015

SECTION B: ACADEMIC RECORD OF APPLICANT

20. Qualifications

Year / Qualification / Institution

Please attach a brief curriculum vitae (maximum five pages) and a copy of your most recent academic record

21. Experience since graduation (including research and, if relevant, work experience and appointments):

______

______

______

______

______

______

______

SECTION C: PROPOSED RESEARCH

22. Nominate the qualification to which the training program will lead:

______

23. Full address of the Western Australian institution for proposed study:

______

______

24. Research Project title:

______

______

25. Broad research area:

______

26. Estimated commencement date (day/month/year):______

27. Estimated completion date (day/month/year):______

SECTION D: COURSE OUTLINE

28. List the course units which you will be undertaking.

29. Provide a brief description of the course.

SECTION E: OUTLINE YOUR RESEARCH PROJECT

Masters and PhDs candidates only. Postgraduate Diploma and Graduate Certificate applicants - move to question 37.

30. Give a brief background to the project (attach extra pages if needed)

31. What are the objectives of the project? (attach extra pages if needed)

32. What do you plan to do. Outline your methodology (attach extra pages if needed).

33. Include a timetable (attach extra pages if needed).

34. How will your project benefit Aboriginal Health in Western Australia?

35. Up to $6,500 per year is available for project costs (see application guidelines). Please provide a brief description and budget breakdown for each year of your study, to show how you will use this funding. Please note the purchase of computer equipment and large items of equipment will not generally be funded.

SECTION F: CLEARANCE REQUIREMENTS

36.INSTITUTIONAL APPROVAL FORM FOR RESEARCH INVOLVING HUMANS

One (1) copy of the completed approval form should be either attached to the original application or sent separately to Healthwayno later than 30 NOVEMBER 2016, or as previously negotiated with Healthway.

APPLICANT USEPlease complete in BLACK type or ink only.

Chief Investigator / SURNAME / TITLE / INITIALS
Scientific Project Title:
Administering Institution:

ETHICS COMMITTEE USE

Y/N
Does this project comply with provisions contained in the NHMRC’s document
“Statement on Human Experimentation and Supplementary Notes”?
Does this project comply with the regulations governing experimentation on humans
within your Institution and within your State or Territory?
Comments, provisos or reservations:
Name of responsible Ethics Committee:
Name of Ethics Committee representative (block letters):
SURNAME / TITLE / INITIAL
Signature: / Date:
Note: / (1)
(2) / This form has been produced in an effort to standardise and effectively record ethics approval for all projects submitted to Healthway. Should it prove inappropriate, an individual statement may be forwarded in lieu. As Healthway cannot provide support if ethics clearance is not provided, it is of utmost importance that this information is received.
If there is no appropriate Ethics Committee at the institution concerned, the Head of Department, or, in the case of individual researchers, the applicants themselves, should ensure that the proposal is submitted to an established Ethics Committee at a hospital or university for comment, prior to completing and signing the rest of the form as an undertaking that the provisions of the NHMRC “Statement on Human Experimentation and Supplementary Notes” will be observed.

In addition to institution ethics clearance, applicants must obtain ethics approval through the:-

Aboriginal Health Council of WA

450 Beaufort Street

Highgate,

WA, 6003

Email –

For information contact: Chelsea Bell, Ethics Officer at Aboriginal Health Council of WA on (08) 9227 1631

SECTION G: AGREEMENT TO ADMINISTER SCHOLARSHIP

37. / Certification by Administering Institution
I certify that should the applicant / be awarded an Aboriginal
Research Training Scholarship, this institution is willing to administer the grant on behalf of the applicant.
Name of certifying officer (please print) / Position
Name of Institution
Signature of certifying officer
Date:

REFEREES -Please note we may contact your referees

38.NOMINATED REFEREE (1)

SURNAME / TITLE / INITIALS

ADDRESS

TELEPHONE NO:FAX:

NOMINATED REFEREE (2)

SURNAME / TITLE / INITIALS

ADDRESS

TELEPHONE NO:FAX:

PRESENT HEAD OF DEPARTMENT

SURNAME / TITLE / INITIALS

ADDRESS

TELEPHONE NO:FAX:

NOMINATED SUPERVISOR (For Masters and PhD only)

SURNAME / TITLE / INITIALS

ADDRESS

TELEPHONE NO:FAX:

SECTION H:CONFIDENTIAL REPORT ON CANDIDATE FOR RESEARCH

TRAINING SCHOLARSHIP

REPORT ON APPLICANT BY NOMINATED REFEREE

(CLOSING DATE FOR APPLICATION –31 JULY 2015)

Name of Applicant:
Institution:
Project Title:

Note to Applicant: Please complete the above and forward to nominated referee with a completed copy of the application.

PART A:

1. / I have known the candidate for / years
I have known the candidate as
(e.g. friend, student, colleague)
I have been his/her
(e.g. tutor, dept head)

PART B

Please provide a brief written report to assist the selection committee in evaluating the candidate’s ability. Briefly comment on the following areas:

a)Candidate’s understanding of the area of study.

b)Ability of the candidate to communicate orally and in writing.

c)Candidate’s ability to understand and evaluate the scientific literature in the field.

d)Ability of the candidate to create and explore new ideas.

e)Knowledge and ability of the candidate to use basic research techniques.

f)State the candidate’s main weaknesses and whether they are likely to affect his/her ability to complete the proposed research.

g)Relevance (in your opinion) of candidate’s research/study area to health promotion in Western Australia.

(Do not exceed 3 pages)

Referee's Details

Name
Institution
Signature / Date

Once completed, please post to:HEALTH PROMOTION RESEARCH PROGRAM

HEALTHWAY

Due date 31 JULY 2015PO BOX 1284

WEST PERTH WA 6872

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