The information given on this form will be an assessment of the eligibility of the candidate and the research project. All personal data will be held in confidence and not disclosed to any third party under any circumstances without permission.

Q1 / SCHEME FOR WHICH YOU ARE APPLYING:
Note that support is designed to be flexible and may be tailored to the candidate’s need. / Postdoctoral award (non-clinical)
Clinicalaward
Q2 / CANDIDATE’S DETAILS
(a) / Surname: / Forenames:
Title (Dr, Ms, Mr): / Nationality:
Contact address:
Work tel no.: / Email address:
(b) / Current position:
Current institution & address:
(c) / Education/training:
Date (mm/yy) / Degrees and
diplomas / Subject / University/Institution
(d) / Previous posts: (list the most recent first)
Dates (dd/mm/yy) / Position and source of funding / University/Institution
(e) / Candidate’s publications (List all publications including any “in press”) Please separate into the categories original research, reviews and editorials, case reports and abstracts
(f) / Is this your first application for funding for this activity? / YES / NO
If no, please give details of all previous approaches to other organisations including reference number(s), if known, the extent of support requested and the date a decision is expected or was given.
TO BE COMPLETED BY CLINICALLY QUALIFIED CANDIDATES ONLY
Q3 / CLINICAL STATUS
(a) / What clinical contract and post do you currently hold?
(b) / What is your intended specialty?
(c) / What credit towards clinical specialist training will be granted if you undertake this award?
(d) / How much clinical work will you perform during the tenure of this award? Divide this into routine as a contribution to service and any clinical work necessary for the project to succeed
Q4 / OUTLINE HOW THIS AWARD WILLCONTRIBUTE TO YOUR CAREER (500 words)
Include reference to your education and training hitherto and what you expect to be doing in 5 and 10 years respectively

Wellcome Centre for Infectious Diseases Research in Africa, Room 3.03.05 Wolfson Pavilion, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory 7925, Republic of South Africa Tel +27 21 406 6084

WSU/SMU NIH U01 Fellowship awards version 0.2 last edited by RJW on 30thOctober2017

Q5 / SPONSOR’S DETAILS AT HOME INSTITUTION(duplicate or delete as necessary: A sponsor may also supervise)
A sponsor must have a contract of employment in the research institution where the candidate will be based and have personal salary support guaranteed for the duration of the proposed fellowship.
(a) / Full name: / Title (Prof, Dr):
Work tel no.: / Email address:
(b) / Position:
Expected date of termination of post: (dd/mm/yy)
Source of salary support:
(c) / With whom do you have your contract of employment?
(d) / Address of institution:
(e) / Sponsor’s research and track record in research mentorship and training (sections iv) and v) should not occupy more than 500 words)
Please provide details of: i) Five recent publications relevant to the application ii) Grant support in the past three years. iii) Research students and fellows sponsored in the past five years. iv) How the candidate’s research will fit with your current research programme; v) Support and mentorship that will be provided to the candidate and how this fellowship will advance the candidate’s research career.
I confirm that the appropriate facilities will be available to the candidate for the duration of the award.

Q6SUPERVISOR’S DETAILS AT HOME INSTITUTION (duplicate or delete as necessary: a supervisor may also sponsor)

The supervisor should have an established position or guaranteed tenure in his or her post for the duration of the grant.

(a) / Full name: / Title (Prof, Dr):
Work tel no.: / Email address:
(b) / Position:
Expected date of termination: (dd/mm/yy)
Source of salary support:
(c) / With whom do you have your contract of employment?
(d) / Address of institution:
(e) / Supervisor’s research and track record in research mentorship and training (sections iv) andv) should not occupy more than 500 words))
Please provide details of: i) Five recent publications relevant to the application ii) Grant support in the past three years. iii) Research students and fellows supervised in the past five years. iv) How the candidate’s research will fit with your current research programme; v) Support and mentorship that will be provided to the candidate and how this fellowship will advance the candidate’s research career.
Please note that relative or apparent inexperience as a supervisor will not factor against, as one of the aims of this scheme is also to develop supervisors. In thesecircumstances the supervisor should concentrate on answering sections iv) and v) above but it would also be advisable to nominate a senior investigator as sponsor
Q7 / SPONSOR AND/OR SUPERVISOR’S DETAILS AT U01INSTITUTION (duplicate or delete as necessary)
(a) / Full name: / Title (Prof, Dr):
Work tel no.: / Email address:
(b) / Position:
Expected date of termination of post: (dd/mm/yy)
Source of salary support:
(c) / With whom do you have your contract of employment?
(d) / Address of institution:
(e) / Sponsor or supervisor’s research and track record in research mentorship and training (sections iv) and v) should not occupy more than 500 words))
Please provide details of: i) Five recent publications relevant to the application ii) Grant support in the past three years. iii) Research students and fellows sponsored in the past five years; iv) How the candidate’s research will fit with your current research programme; v) Support and mentorship that will be provided to the candidate and how this fellowship will advance the candidate’s research career.
Q8 / RESEARCH ACTIVITY
(a) / Proposed start date: / Period for which support is sought (in months):
(b) / Activitytitle:
(c) / Outline of research activity(no more than 1200 words) 2 embedded items (Figures or Tables) are permitted and will not add to the word count. Word counts will be checked and applications returned if the limit is exceeded.
Please include (a) The research question (i.e. hypothesis) (b) Aims that address the hypothesis (c) Brief background and relevance of the project including any key preliminary data. (d) A research plan that addresses the aims (e) The relationship between the participating institutions (f) timescale and power considerations (g) contingency plans
Q9 / OUTLINE COST OF THE PROPOSALPlease estimate the following:
Candidate’s salary/stipend requested (inc. employer’s contributions)
Please attach relevant scales upon which you have based your estimate / R
Other salary requests / R
Materials and consumables / R
Animals / R
Equipment / R
Travel / R
Miscellaneous / R
Total: / R
Indirect costs should not exceed 8% total and cannot be awarded to UCT.
Q10 / JUSTIFICATION FOR COST OF THE PROPOSAL
Please justify costs under the headings above in less than 400 words
Q11 / APPROVALS
Please describe any institutional, local and national governmental, regulatory and ethical approvals that will be required in less than 400 words. Please provide the Federalwide assurance number of your institutional review board if it is involved in consideration of the work

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Q12 / SUGGESTED EXTERNAL REVIEWERS
Please nominate an external reviewer(s) (include their e-mail address is important) who will have no conflicts of interest. The use of these reviewers will be at our discretion. You should not nominate recent or present collaborators and you should not discuss this proposal with such nominees. Reviewers will be asked to reveal any possible conflicts of interest. (N.B. The suggested names will be removed from the application at the time of processing so that your nomination will not be revealed).
Q13 / EQUITY
This scheme is open to all persons who fulfil scientific eligibility criteria. The funding was provided to specifically redress lack of research opportunities for persons based in historically disadvantaged universities in South Africa.
1. Sex: / Male / Female
2. Date of birth:
3. Nationality:
4. Ethnic origin: / White
Coloured
Black African
Indian
Other / Please describe:

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