WCH FOUNDATION

MS McLeod Research Fund

Postdoctoral Fellowship

RESEARCH COMMENCING IN 2018

Application Form

1.  Personal Details:

NAME:
(Title / First / Surname)
Date of Birth: / Place & Country of Birth:
Australian citizenship and residential status:

2.  Contact Details

Current Position:
Postal/Delivery Address:
(Floor / Level / Building)
Department /Division:
Institution (currently employed by):
WCHN / SA Pathology (WCH Campus) / SAHMRI (WCHN Campus)
Telephone (work): / Mobile:
Email:

3.  Eligibility

3.1 Have a minimum of one year and a maximum of five years post-doctoral research experience: / YES / NO
3.2 Certified copies of academic records / transcripts of each tertiary institution attended are required. (Please attach with signed original application).
ATTACHED: YES / NO

4.  Curriculum Vitae

Please include a CV as a separate document outlining the points listed below (Maximum 3 pages):
4.1  Education (include academic and professional qualifications, date conferred, Institution conferring)
4.2  Employment history (include present position/appointment at WCHN)
4.3  Awards and Fellowships received
4.4  Completed research projects, including research grant achievement and brief summary of research projects
4.5  Research Publications
4.6  Research Presentations
ATTACHED: YES / NO

5.  Outline of research project

5.1 Name of Department(s): (of WCHN / SAHMRI / SA Pathology) in which the research work will be undertaken
5.2 Title of the research project:
5.3 Abstract of the research project: in lay terms (300 words or less)
5.4 Brief description of the research project: (up to 6 pages maximum), including research objectives, the significance for paediatric health, research methods, data analysis and interpretation techniques
5.5 Any special facilities required, particularly in regard to equipment and space?
5.6 A letter from the Head of the Department, supporting the application, and confirming that the Department can provide appropriate facilities and supervision for the proposed research, should the application be successful.
If applicable, include how the Department will cover costs above the awarded fellowship payment.
ATTACHED: YES / NO

6.  Other information

The applicant should provide any other information which may help in the assessment of the application.

7.  Referee reports

The applicant must request a written report from three (3) referees. This report should include the referees name, address, and contact details and outline the applicant’s academic abilities and personal suitability to undertake the proposed research, and who may be prepared to evaluate the project proposal.
Reports may be forwarded to the Research Grants Officer by the closing date;
Hard copy: C/- Research Secretariat, Level 2, Samuel Way Building, Women’s and Children’s Health Network, 72 King William Road, NORTH ADELAIDE SA 5006; or via
Email: (as a seperate attachment)
Please provide the names and contact details for each of your nominated referees below:
Referee 1
NAME:
(Title / First / Surname)
Department /Division: / Telephone:
Email:
Referee 2
NAME:
(Title / First / Surname)
Department /Division: / Telephone:
Email:
Referee 3
NAME:
(Title / First / Surname)
Department /Division: / Telephone:
Email:

8.  ETHICAL/SAFETY and Governance CLEARANCES

This section MUST be completed. To verify what clearances are required refer to:

http://www.wch.sa.gov.au/research/committees/index.html.

Approval required / Approval attached / Approval number(s)
Human Research Ethics / Yes / No / Ethics:
Governance:
Is the title of you proposed project the same as the approve ethics
Yes No
Yes
No / If NO approval, has application been submitted: Yes No
If NO, when will you submit: /
Animal Ethics / Yes / No / Ethics:
Is the title of you proposed project the same as the approve ethics
Yes No
Yes
No / If NO approval, has application been submitted: Yes No
If NO, when will you submit: /
Institutional Biosafety / Yes / No / Ethics:
Is the title of you proposed project the same as the approve ethics
Yes No
Yes
No / If NO approval, has application been submitted: Yes No
If NO, when will you submit: /
If you have indicated above that ethics approval is not required, please provide justification below that your study does not involve any animals, patients, patients’ families, patient tissue (including stored tissue), patient information and/or staff. It is recommended you discuss your project with the Chair of the WCHN relevant Ethics Committee (HREC / AEC / IBC) to clarify this matter and provide written confirmation from the relevant Chair.

Please note if successful:

v  The applicant must provide notification of ethics and governance approval to the Research Grants Officer by 31 March.

v  If this application has a different title from that which is on the ethical/safety clearance, you MUST provide a statement to the relevant committee requesting the new title be added and state if there are any changes to the protocol (ie an amendment to the protocol).

v  On receipt of the HREC letter indicating the addition of a title has been approved– please forward a copy of the letter to the Research Grants Officer.

v  Approval for your project and processing payment of the award will not been granted until written confirmation is received from the relevant ethics/safety committee and/or Research Governance Officer.

9.  Certification

Signatures date and endorsement
All applications are to be signed, dated and endorsed, as outlined below, by the applicant, Department Head, Divisional Director and Executive Director or institutional equivalent.
Applicant
Signature: ______Date: ______
Endorsement of Application
Department Head
Acknowledging consent and support for the application, and budget provision for backfill (if required) during the Scholarship
Name:
(Title / First / Surname)
Signature: ______Date: ______
Divisional Director
Name:
(Title / First / Surname)
Signature: ______Date: ______
Executive Director
Name:
(Title / First / Surname)
Signature: ______Date: ______

10.  Submitting Application

10.1  Applicants must submit an original signed copy plus five (5) photocopies of the application and should to the Research Grants Officer, C/- Research Secretariat, Level 2, Samuel Way Building, Women’s and Children’s Health Network, 72 King William Road, NORTH ADELAIDE SA 5006
10.2  Applicants must also submit One electronic copy of the application (in Word Format), and should be sent to:
NB: Late and/or unsigned applications WILL NOT be accepted.

APPLICATIONS CLOSE: 4.00pm, Monday 16 October 2017

On behalf of:

The Trustees of the MS McLeod Research Fund

WCH Foundation Inc.

September 2017

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