WCH FOUNDATION

2014Matthew Scriver

PICU Nurses Scholarship

APPLICAION FORM

  1. Personal Details

Title: / First Name: / Surname:
  1. Contact Details

Postal/Delivery Address:
(incl. floor/level/building)
Department /Division:
Telephone (work): / Mobile:
Email:
  1. Curriculum Vitae(short Personal CV –to be included as an attachment to this application)

This should include (amongst other relevant info):
3.1Education
3.2Employment history
3.3Awards
3.4Research experience – Include completed research projects, research grant achievement and brief summary of research projects
3.5Publications
3.6Presentations
  1. Outline of research project

4.1 Title of the research project
4.2 Name of Department (WCHN department in which the research work will be undertaken)
4.3 Abstract of the research project:in lay terms (300 words or less)
4.4 Brief description of the researchproject
NB: (4 pages or less), should include research objectives, recruitment and consent (if applicable), research methods, data analysis and interpretation techniques, the significance of the study for paediatric health care in a PICU setting.
4.5 project findings
Outline where and in what format the applicant is aiming to publish and/or present the project findings
4.6 Name of the proposed supervisor(s)
Supervisor 1
Title: / First Name: / Surname:
Department/Division:
Telephone (work): / Mobile:
Email:
Supervisor 2
Title: / First Name: / Surname:
Department/Division:
Telephone (work): / Mobile:
Email:
4.6Proposed commencement Date
  1. Department letter of Support

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 – to be included as an attachment to the application.

  1. Referee reports

The applicantmust request a written report from two (2) referees. This report should include the referees’ name, address, and contact details and outline the applicant’s abilities and personal suitability to undertake the proposed research project.
Reports may be forwarded by the closing date: 4pm Monday 16 December 2013 in hard copy to: The Matthew Scriver PICU Nurses’ Scholarship, C/- Research Secretariat, Level 2, Samuel Way Building, Women’s and Children’s Health Network, 72 King William Road, NORTH ADELAIDE SA 5006 or emailed as attachments to
REPORT ATTACHED: YES / NO
Referee A
Surname: / First Name: / Title:
Postal/Delivery Address:
(Floor / Level / Building)
Department /Division:
Telephone (work): / Mobile:
Email:
Referee B
Surname: / First Name: / Title:
Postal/Delivery Address:
(Floor / Level / Building)
Department /Division:
Telephone (work): / Mobile:
Email:
  1. ETHICAL/SAFETY CLEARANCES

refer to check clearances required
Please note:
It is the responsibility of the applicant to provide notification of clearances to the Research Secretariat before the research commences.
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 stating that the protocol is identical and requesting that the new title be added.
Approval for your project will not been granted until written confirmation is received from the relevant ethics/safety committee.
Approval required / Approval attached / Approval number
Animal Ethics Committee / Yes
No / Yes
No / If no approval, has application been submitted: Yes/No
If no, when will you submit://
Human Research Ethics Committee / Yes
No / Yes
No / If no approval, has application been submitted: Yes/No
If no, when will you submit://
Institutional Biosafety Committee / Yes
No / Yes
No / If no approval, has application been submitted: Yes/No
If no, when will you submit://
  1. Other information

The applicant should provide any other information which may help in the assessment of the application, including a budget detailing how the money will be spent.
  1. Certification

All applications are to be signed, dated and endorsed, as outlined below, by the Applicant, Department Head, Divisional Director and Executive Director.
Applicant
Signature: ______Date: ______
Endorsement of Application
Department Head
Acknowledging consent and support for the application and budget provision during the Scholarship
Name: ______
Signature: ______Date: ______
Divisional Director
Name: ______
Signature: ______Date: ______
Executive Director
Name: ______
Signature: ______Date: ______
  1. Submitting Application

10.1The applicant is required to submit the original signed hard copy of the application form plus four (4) hard copies:
The Matthew Scriver PICU Nurses’ Scholarship
C/- Ms Katherine McPhail,
Research Grants Officer
Research Secretariat
Level 2, SamuelWayBuilding,
Women’s and Children’s Health Network
72 King William Road
NORTH ADELAIDE SA 5006
10.2One electronic copy of the application is required (in Word Format), and should be sent to:
By 4.00pm on the closing day: Monday 16 December 2013
NB: Late applications WILL NOT be accepted.

October 2013