The Hospital Research Foundation Research Travel Awards(BHI)

The Hospital Research Foundation Research Travel Awards(BHI)

Application Form

1. PERSONAL INFORMATION

Name of applicant and current position:

TitleGiven namesFamily namePosition

Contact details:

Phone numberEmail address

Address at BHI:

Are you an HDR student? Yes ☐

Date of commencement of PhD/Masters: Expected completion date:

Are you a non-student BHI Researcher? Yes ☐

Group and administrative department:

Have you previously been awarded a THRFResearch Travel Award in this calendar year?:Yes ☐ No ☐

Funds sought in this application: (please tick one box)

National conference☐

International conference☐

National visit to another academic institute☐

International visit to another academic institute☐

National conference and organised visit to another academic institute☐

International conference and organised visit to another academic institute☐

1. DETAILS OF CONFERENCE ATTENDANCE:

Name of Conference:

Location of Conference:

Date/s of Conference:

Have you applied for a conference travel award: Yes ☐No ☐

If no above provide a reason:

Name of academic institution for lab visit:

Name of lab and name of hosting researcher:

Location of lab:

Date/s of lab visit:

Proposed activity at the conferenceand/or hosting academic institution (including any existing collaborative links and expected outcomes).

Please indicate the career benefits of the proposed activitye.gChair, presentation, panel etc.

3. FINANCIAL SUPPORT FROM OTHER SOURCES (Please state amount received)

University:

Supervisor:

External sources (Including conference travel awards):

Own funds:

Total support from other sources:

4. FINANCIAL SUPPORT REQUESTED (Please state costs):

$ Amount
Airfares:
Other Fares:
Conference Registration Fee (If applicable):
Visa (If applicable)
Accommodation
Funds already secured (total of question 3 above)
TOTAL (i.e. the support sought after deducting the funds already secured):

5. SIGNATURES and Statement

______

Signature of applicantPrint name of applicantDate

______

Signature of supervisorPrint name of supervisorDate

SUPERVISOR STATEMENT on expected training and career benefit of staff member/student presenting at the conference:

6. CHECKLIST

Required:

☐A completed application form.

☐Curriculum Vitae (up to 4 pages) indicating your track record (publications, abstracts, prizesand other indicators of academic achievement)

As relevant:

☐Copy of abstract showing BHI and relevant University affiliation

☐Copy of abstract acceptance.

☐Copy of conference registration, travel itinerary

☐Copy of approved University Notification to Travel Form or CALHN Conferences and other official Travel Form.

7. SUBMISSION

Please submit final application (complete with relevant signatures and supporting papers) in one pdf file to r processing. A recommendation will be forwarded by the BHI to Paul Flynn, CEO THRF for his consideration.

8. BHI RECOMMENDATION

To CEO: See attached Review sheet from TQEH Research Secretariat

Page 1 of 4