TCRN Conference Professional Development Grants 2016

Round 2

Application Form

Applications close 10am, Monday8 February 2016

For travel between 1 February 2016 -30 June 2016

Please read the TCRN Conference & Professional Development Grants 2016 for Round 2Guidelineswhile completing this application form.

Note:

  • No late applications will be accepted
  • Please complete ALL relevant sections of this application and ensure that all information is correct and complete. Proof of invitation to speak or acceptance of abstract is necessary. Incomplete or incorrect applications WILLNOT be considered.
  • Applicants who wish to travel in February are strongly encouraged to submit their applicationsas soon as possible. Applications will be assessed as we receive them.
  • Please note that any travels that have already commenced or completed before submitting the application will not be considered.

I am applying for (select one):

Conference Grant / Professional Development Grant / PhD- Conference Grant

Section 1: Applicant Details

  1. First name
/ Surname
  1. Mobile

  1. Email

  1. Employer
/ Border Medical Oncology Research Unit
Prince of Wales Hospital
St George Hospital/Sutherland Hospital
The Royal Hospital for Women / The University of New South Wales
University of Technology, Sydney
Calvary Health Care
Other (list):
  1. Profession
/ Administrator
Allied health professional (list):
Clinician – Researcher
Clinician – nurse
Consumer
Health Services Manager
Research Assistant
Post-doc Fellow / Senior Researcher
PhD student
PhD supervisor name:
Junior medical staff (only if you are not eligible for TESL leave)
Other (list):
  1. Broad Research Area
/ Basic Science
Clinical Medicine and Science
Preventive Medicine / Health Services Research
Public Health
N/A
  1. Translational Pipeline
/ All
N/A / T1
T1/T2 / T2
T2/T3
T3
  1. Tumour Group Focus
/ All Cancers
Breast Cancer
Colorectal Cancer
Gynaecological Cancer / Haematological Cancer
Head and Neck Cancer
Neurological Cancer
Skin Cancer / Respiratory Cancer
Upper Gastrointestinal Cancer
Urogenital Cancer
Other (list):

Section 2: Proposed conference/course

  1. Conference/course name

  1. Conference/course
city and country
  1. Conference/course
venue and address
  1. Conference/course date
/ Start date: / End Date:
  1. Are you invited to speak?
/ No (go to Q6 below)
Yes Attach a copy of the invitation to this application.
  1. Are you submitting an abstract or a paper?
/ No (eligible for Professional Developmentgrant only)
Yes→Type of presentation: Oral Poster Other:
→Abstract accepted? Yes No Pending
Attach a copy of abstract and confirmation of acceptance to this application.

Section 3: Addressing the Selection Criteria

1.Please tell us about yourselfand your professional interests and experience either in cancer research orcancer care service delivery.

Max 150 words

2.Please provide three (3) learning objectives for the proposed conference/course and describe how achieving these will help you excel in your current role and how this will benefit the TCRN.

Learning objectives / Benefit to your current role and the TCRN:
1. / 1.
2. / 2.
3. / 3.

3. Dissemination of the knowledge you will gain by undertaking this activity is very important to the TCRN. Please indicatewhich of the following you are prepared to do on your return.

  • Present your paper or talk at a TCRN member event?YesNo
  • Present your paper or talk at a public forum hosted by the TCRN?YesNo
  • Contribute an article forthe TCRN’s website? YesNo
  • Contribute an article forthe TCRN’s newsletter, Nexus?YesNo

Section 4: Cost Estimates

PLEASE COMPLETE ALL RELEVANT SECTIONS OF COST ESTIMATES,INCLUDING VENDOR INFORMATION.
FAILURE TO PROVIDE ALL RELEVANT INFORMATION WILLDISQUALIFY YOUR APPLICATION.

Cost / Vendor
1 / Transportation / National airfare
(economy only) / $
International airfare
(economy only) / $
2 / Accommodation / Cost per night / $
# of nights
Total accommodation cost / $
3 / Conference/course registration fee / $
4 / Transfers (flat rate only)
Select one / National = $50
International = $100 / $
TOTAL GRANT REQUESTED / $
  • Up to $1,000will apply to national conference & professional development.Up to $3,000 will apply to international conference & professional development.
  • All costs must be given in Australian dollars.
  • No documentation will be required at the time of application however cost estimates will be checked to ensure they are reasonable. The TCRN reserves the right not to fully fund costs if these are deemed to be too high.

Additional information:

  1. The TCRN understands that the total cost of travel and registration may exceed $1,000 (national) or $3,000 (international). If your total costs exceed these amounts, please indicate from where the additional funds will be sourced, e.g. employer, personal funds, etc.
  1. If you have another funding source that ispartially funding this travel, please provide the funder information andthe amount funded.
  1. I confirm that I have not received and shall not accept funding from another source that duplicates the

funding awarded by the TCRN for this conference/professional development opportunity.

(initial)

  1. I confirm that I have not received and shall not accept any funding from another Cancer Institute NSW Translational Cancer Research Centre or Translational Cancer Research Unit. (initial)

Section 5: Signatures

(a) Applicant

By signing this application form Icertify that all details given in this application are complete, correct and true. Iunderstand that the provision of false or misleading information may result in approved funding being withdrawn or reimbursement to the TCRN being required.

Applicant Name
Signature / Date / ___/___/___
(b) Employer authorisation and approval

I support the candidate’s application to attend this nominated conference/course.

Name / Title / Signature / Date
___/___/___
Translational Cancer Research Network
A translational cancer research centre program funded by the Cancer Institute NSW
Level 4 | Lowy Cancer Research Centre | The University of New South Wales | UNSW Sydney NSW 2052
T: +61 2 9385 1395 | | / 1 of 4