TownsvilleHospital and Health Service

APPLICATION FORM FOR FUNDING ASSISTANCE TO ATTEND CONFERENCES, WORKSHOPS and SEMINARS, and SPECIAL APPLICATIONS

This application document is designed to assist the applicant in producing the information that the Research Trust Fund Advisory Committeewill need to evaluate the application.

Please use a size 11 Arial font when completing the application. Page limits are included in each section. Information beyond these page limits will not be considered.

Email the signed completed application to: Hard copies are not required.

Please place in box 1 the name of the applicants. Please note that the applicant must be an employee of the TownsvilleHospital and Health Service.
  1. Applicant Name:

  1. Applicant email:
/
  1. Applicant Phone no:

  1. Position at THHS:

  1. THHS Service Group and Department:

Complete either Question 6 or 7 depending on funding sought
  1. Details of conference / workshop / seminar for which funding is sought(attached flyers / conference brochure etc if available):

  1. Details of project / special consideration (Special Application) for which funding is sought:

  1. Provide a short statement on how this will positively impact on service delivery in the Townsville HHS (1/2 page maximum):

Complete Q9 if funding is requested in Q 6. Not required for funding requested in Q7
  1. Are you eligible for professional development entitlements under a certified agreement? YES NO

Only required if Q 9 is completed as YES.
  1. If yes, has this financial year’s Professional Development Entitlement Allowance allocation been expended? YES NO
If no, you are not eligible to apply for SERTA Moneys
Complete Q11 if funding is requested in Q6
  1. Budget Note: Expenses for Taxis, Car Parking, Meals, Travel Allowance will not be considered

Type of Assistance
(add rows if required) / SERTA Moneys request
($ amount) / Contribution by Applicant / Contribution by Work Unit / other parties
e.g. paid leave
Registration fee
Leave
Other (please state)
Total
Complete Q12 if funding is requested in Q7
12. Budget(provide breakdown of amount requested)
Type of Assistance
(add rows if required) / SERTA Moneys request ( $ amount) / Contribution by Work Unit / other parties
Maximum funding up to $1 000 per application only is provided from the SERTA Moneys for conference / workshop / seminar attendance. Funding in Q11 will only be granted for conference registration fees unless there are exceptional circumstance.
There is no maximum funding for Special Applications (NB. funding is not unlimited)
Sign-off

The Applicant has read the terms and conditions of this Application, and the Applicant agrees to abide by these and other conditions attached to any approval given.The Applicant confirms that they have not received funding from the SERTA Moneys for conference / workshop / seminar attendance in the current financial year.

Applicant name / Applicant signature / Date
I believe that this conference/workshop will be beneficial to both the individual and the unit and this application for financial assistance is supported by the relevant Townsville HHS department.
Service Group Director Name / Service Group Director Signature / Date

Townsville Hospital and Health Service

Terms and Conditions

These Terms and Conditions are mandatory and apply to an application for funding to attend conferences, workshops and seminars and special applications to use SERTA Moneys, irrespective of whether the funding is approved and/or paid.

By signing this Application, the Applicant/s (hereinafter referred to as the Applicant) acknowledge and agree that they have read and understood this Application, including these Terms and Conditions.

  1. Funds must only be used to attend the conference, workshop, seminar or other purpose approved by the Research Trust Fund Advisory Committee and in accordance with the timeline and for the purposes stated in the application and as approved by the Research Trust Fund Advisory Committee.
  2. Expenses paid by the Applicant will only be considered for reimbursement (if eligible) upon provision of supporting tax invoices to the THHS Research Education, Support and Administration Unit.
  3. The Townsville HHS Research Education, Support and Administration Unit is responsible to manage and co-ordinate access to the funding.
  4. If the Applicant requests a variation to the funding approved, the Applicant must apply to the Chair of the Research Trust Fund Advisory Committee. The Chair will consider whether there is merit in the request and if there is, and the variation is substantive, the Chair may submit the request to the Research Trust Fund Advisory Committee for assessment. If the request is not substantive, the Chair may elect to exercise their discretion under their delegated authority.
  5. The Applicant must provide a report/s (template to be provided) for review by the Research Trust Fund Advisory Committee on the earlier of:

(a) Within 14 days of attending the conference, workshop or seminar; and

(b) The date notified by the Research Education, Support and Administration Unit from time to time.

  1. The Applicant is responsible to comply with all Government and Townsville HHS applicable financial and administrative prerequisites and procedures. This includes, but is not limited to completion of any Application for Conference Leave Form (if applicable).
  2. The Applicant must comply with all reasonable directions/instructions issued by the Research Education, Support and Administration Unit relating to the administrative prerequisites and procedures.
  3. If at the end of the conference, workshop or seminar, or as part of any special application approved, the Applicant is holding any funding (or any part thereof), the Applicant must return the funding (or part thereof) to the Townsville HHS. If any funding is unspent, the Applicant is not entitled to apply this funding for any other purpose.
  4. In the event that the Applicant fails to comply with these Terms and Conditions or in the event that Townsville HHS consider that any part of the Application is found to be incorrect, false or misleading, Townsville HHS may, by written notice to the Applicant cancel the approval of the funding and take such action as Townsville HHS consider appropriate. This may include repayment by the Applicant of any moneys paid on behalf of Townsville HHS as part of this Application.

RESEARCH Grant ASSESSMENT TOOL AND APPROVAL

APPLICATION FOR FUNDING ASSISTANCE TO ATTEND CONFERENCES, WORKSHOPS and SEMINARS

Name of applicant
Name of application
SERTA grant Application No:
Question / Response / Comments
1. Does the Application comply with the Health Service Directive re SERTA Purposes?* / YES / NO
2. Will this Application positively impact on service delivery in the Townsville HHS? / YES / NO
3. Recommend approval of funding? / YES / NO
4. Amount approved:
5. If no, please provide a rationale for not recommending the funding:
Dr Tracey Bessell
Print Name / Signature / Date
Chair
Research Trust Fund Advisory Committee

*SERTA Purposes

(a) To provide grants for study, research, conference and educational purposes for medically-qualified employees of the Townsville HHS

(b) To provide equipment or property for operational, research and education purposes

(c) To provide funds to the hospital to employ staff who are engaged in research or education

(d) To support non-medically qualified HHS employee for the purposes as set out in paragraph (a) and (b), on the recommendation of the Committee

SERTA Conference Funding Feb 2017