ContactInformation

ChiefInvestigator A (CIA)

Title:Firstname:Initial:Last name:

Position:

PhoneNumber:

E-mailAddress:

Organisation:

DepartmentorCentre:

Faculty:

Full Postal Address – work (including DX#):

AdministeringInstitution

Organisationname:

ABN:

ContactPerson:

PhoneNumber:

E-mailAddress:

PostalAddress:

Employment

How long have you been employed by this organisation?

When is your position’s renewal date?

Research Team

NOTE: Each Chief investigator should complete Attachment A (See Page 8)

ChiefInvestigator B (CIB)

Title:Firstname:Initial:Last name:

Position:

PhoneNumber:

E-mailAddress:

Organisation:

DepartmentorCentre:

Faculty:

ChiefInvestigator C (CIC)

Title:Firstname:Initial:Last name:

Position:

PhoneNumber:

E-mailAddress:

Organisation:

DepartmentorCentre:

Faculty:

Project Overview

Title:

Total funds requested:

(Maximum available is $250,000)

Overview of the project (lay description only) - who will benefit from the research and why there is a need and when translational outcome is reasonably expected.

Expected outcome of the research and when translational outcome can be reasonably expected and why you are confident on this date. (lay description)

Briefly describe the Preliminary studies which validate the feasibility and delivery milestones of the proposed study (Limit: Half Page)

Strategic fit (lay description) – outline the translational and innovative aspects of the research.

Briefly describe the research plan

Limit one page.

Outline the research teams experience in innovation and collaborations, including commercial collaborations and translating evidence into practice or public policy

Limit - half page

Milestones

Pleaseindicateyourkeymilestones,alongwiththecompletiondateandassociatedcosts

Milestone / CompletionDate / Cost item / Cost $

Confirmation of external funding support

If applicable, please provide a copy of any external funding support via copy of letter from third party funder when you submit your application to:

Certifications and Approvals

Ethical Implications of the proposed research

Does this research involve any of the listed activities?

Experimentation on human subjects?Yes/NoProvide copy of the current approval.

Experimentation on animals?Yes/NoProvide copy of the current approval.

Use of GMO/GM productsYes/NoProvide copy of current OGTR approval

Signature of Chief Investigator(s)

I declare that the information supplied on this application, and any accompanying documentation to be true and correct.

If I/we am/are successful in obtaining a grant, the research will not commence until it has been approved by the relevant institutional committee/s.

Printed name of CIA:

Signature of CIA ______Date//201

(if relevant) Printed name of CIB:

Signature of CIB ______Date//201

(if relevant) Printed name of CIC:

Signature of CIC ______Date//201

Certification by the CALHN Director of Research

I certify that the project is appropriate to the general research facilities of the Royal Adelaide Hospital and approve the activity to be carried out in the appropriate department/group.

Director of Research: Prof John Beltrame

Director of Research endorsement:______

Date//2017

Attachment A: Chief Investigator Details

NAME:______

Are you:  CIA CIB  CIC

Current and Past funding

Please list any research funding you have received related to this research in the last five years:

From - to / Amount / Source

List publications (including books) for 2012-2017 only. This is required for Track Record purposes.

List publications in date order, with the most recent first. Please list all authors, title, journal detail, date.
No page limit.

Opportunity to make a statement regarding Track Record relative to opportunity

1