ParliamentaryAcademic Fellowship 2016 Application form

Please complete using Verdana size 9 font in black and submit an electronic copy the completed form, a two-page CV to . Please note that the application will be made ineligible if any of the sections below are left blank. We would be grateful if you could also complete the diversity monitoring form attached and submit this with your application.

SECTION 1: Applicant Details
Surname / Title
Forename(s)
Source of funding / EPSRC IAA ESRC IAA
University
Department
Preferred Correspondence Address
Personal telephone (Day) / Personal telephone (Evening)
Personal email address
University email address
Please confirm that you are an EU citizen or that you have the right to work in the United Kingdom (please note, you will be required to provide evidence of this before commencing the Fellowship / Yes I can confirm that I am an EU Citizen / I have the right to work in the UK
Please indicate if you wish to apply for Directed Call or Open Call of the Parliamentary Academic Fellowship Scheme / Directed Call (please go to Section 2)
Open Call (please go to Section 3)
ALL APPLICANTS SHOULD COMPLETE SECTIONS 4 -5
If you need any additional support in order to participate in an interview (and/or to take up a Fellowship at Parliament), please outline your requirements here. If you would like more information, please contact Dr Caroline Kenny at POST or call 020 7219 0743.
SECTION 2: Further Details (FOR APPLICANTS TO DIRECTED CALL ONLY)
Please indicate the title of the project that you wish to apply for
Preferred start date of fellowship / Expected end date of fellowship
Reason for applying
Please provide a brief explanation of why you are applying for this Fellowship andwhat you intend to get out of the Fellowship in terms of impact/s and specific outputs.
Please do not exceed 200 words.
I confirm that the above particulars are correct
Signature: / Date:
APPLICANTS TO DIRECTED CALL PLEASE NOW GO TO SECTION 4.
SECTION 3: Outline Application (FOR APPLICANTS TO OPEN CALL ONLY)
Title of Project
Expected start date of fellowship / Expected end date of fellowship
Preferred Parliamentary Host Office
Summary of project
Please provide a brief explanation of your proposed project indicating how it is of relevance to Parliament.
Please do not exceed 200 words.
Explanation of how the proposed project is relevant to Parliament
Please provide a brief explanation of how your proposed project is of relevance to Parliament.
Please do not exceed 200 words.
I confirm that the above particulars are correct
Signature: / Date:
APPLICANTS TO OPEN CALL PLEASE NOW GO TO SECTION 4.
SECTION 4: Statement of support from Head of Department
This part of the form should be completed by your Head of Department:
I confirm that the above particulars are correct. If the application is successful, I give my permission for the above applicant to suspend their teaching and/or administrative duties for the period of the fellowship (as outlined below).
Name (please print):
Signature: / Date:
SECTION 5: Statement of support from Administrative Lead of the IAA Grant Holder
This part of the form should be completed by the Administrative Lead of the IAA Grant Holder:
I confirm that the applicant is currently employed at this institution and that the above particulars are correct. I can confirm that I have discussed this proposal with the applicant and have agreed the level of funding that will be provided to the applicant, and what this funding can be used towards, should the application be successful. I understand that a condition of the fellowship is that the applicant remains employed at the University during the period of thefellowship.
Name (please print):
Start date of fellowship: / End date of fellowship:
Signature: / Date:

Diversity Monitoring Questionnaire

(If you require a large print version of this form, please contact the Diversity Team on 020 7219 2948 or )

The House of Commons and House of Lords are committed to equal opportunities. Applications are welcome from all qualified individuals irrespective of gender, marital status, age, race, colour, disability, religious affiliation or sexual orientation. Both Houses are also committed to ensuring fairness and equal access to all temporary, agency, casual and permanent employees and Fellows, and to avoiding unjustified discrimination in the recruitment, retention, training and development on the basis of gender, nationality, ethnicity, disability, age, sexual orientation, religion or beliefs, gender identity or any other irrelevant grounds.

Monitoring details of applicants’ diversity data enables us to review our recruitment and selection processes to ensure that they are barrier-free.To do this we need you to complete this questionnaire. The information you provide will be treated in the strictest confidence. It will be held in a password protected folder on the Parliamentary Office of Science and Technology (POST) Parliamentary ICT system. Access to this folder is restricted to the Social Science Section Team at POST and the Director of POST. This means access to the data is tightly controlled. The information will be processed in accordance with the requirementsof the House of Commons and/or House of Lords Data Protection Policy and the Data Protection Act 1998. If you have any concerns about thecollection and use of this information please contact Dr Caroline Kenny. General information aboutyour Data Protection rights can be sought from the Data Protection Officer on tel. 020 7219 2032 or from the Information Commissioner’s Office at or tel. 08456 30 60 60. The information provided will be destroyed in line with the Parliamentary Authorised Records Disposal Practice.

Please answer all sections ticking only one box in each section. The options are listed alphabetically.

Section A

Full Name: …………………………… Age......

Section B – Ethnic Background

Which of the following do you feel you most identify with?

AsianORMixed Ethnic Background

A) BangladeshiI) Asian and White

B) IndianJ) Black African and White

C) PakistaniK) Black Caribbean and White

D) Other Asian background (specifyL) Any other mixed ethnic

below if you wish)background (specify below if you wish)

…………………………………………….…………………………………………….

ORBlackORWhite

E) AfricanM) Any White Background (Specify

F) Caribbeanbelowif you wish)

G) Other black background (specify

below if you wish)……………………………………………………….

…………………………………………….

ORAny Other Ethnic Background

N) Any other ethnic background 

ORChinese(specify below if you wish)

H) Any Chinese background (specify 

belowif you wish)……………………………………………………….

…………………………………………….O) Prefer not to say 

Section C – Nationality

Which of the following do you feel you most identify with?

A) British or Mixed BritishC) Prefer not to say

B) Other (specify below if you wish) ………………………………………......

Section D – Disability

The Equality Act 2010 defines a person with a disability as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities.

Do you consider yourself to have a disability?Yes  No  Prefer not to say 

Section E – Dependants

Do you have any dependants?

(Children under 16, children with a disability under 18, adults that are in need of care)

Yes NoPrefer not to say

Section F – Sexual Orientation

What is your sexual orientation?

A) Bisexual

B) Gay Man

C) Gay Woman / Lesbian 

D) Heterosexual / Straight

E) Other (Please specify if you wish) ......

F) Prefer not to sayD

Section G – Religion and Belief

Below is a list of religions and beliefs that are the most commonly found in Britain. They are listed in alphabetical order and not intended to signify rank in terms of importance. Furthermore we acknowledge that the list is not exhaustive and if your religion is not specifically listed please insert your religion in the space provided.

Which belief, non-belief or religion do you feel you most identify with?

A) AgnosticismF) Islam

B) AtheismG) Judaism

C) BuddhismH) Sikhism

D) ChristianityI) Any other Religion or Belief 

E) HinduismJ) Prefer not to say 

(Please specify belowif you wish)

……………………………………………………….

Section H – Gender Identity

What is your gender identity?

Man (including trans man)Women (including trans women)

Other Gender Identity (e.g. androgyne person)Prefer not to say 

…………………………………

Is your gender identity the same as the gender you were assigned at birth?

Yes NoPrefer not to say

Please check that you have answered questions.

Thank you for completing this form