Please refer to the UK Lectureship Guidance for Applicants and Conditions of Award before completing this Application Form / For Office Use Only

1.  Which type of Lectureship do you wish to apply for? Please tick the appropriate box.

(a)  A Clinical Lectureship for Nurses and Allied Health Professionals

(b)  A Senior Clinical Lectureship for Nurses and Allied Health Professionals

(c)  A Clinical Lectureship for Medical Professionals

(d)  A Senior Clinical Lectureship for Medical Professionals

(e)  A Non-Clinical Lectureship

(f)  A Senior Non-Clinical Lectureship

(g)  A Reader Award (Clinical)

(h)  A Reader Award (Non-Clinical)

Please note:

·  If you are clinically qualified and still spending some of your time in clinical training and/or practice, you should apply for a Clinical Lectureship, Senior Clinical Lectureship or Reader (Clinical).

·  If you are clinically qualified but have left, or wish to leave clinical practice, you should apply for a Non-Clinical Lectureship, Senior Non- Clinical Lectureship or Reader (Non-Clinical).

·  Non-clinically qualified researchers are also welcome to apply for the Non-Clinical Lectureship, Senior Non Clinical Lectureship or Reader (Non-Clinical) awards.

2

2.  Details of the Candidate

Surname / Forename(s) / Title / Position

2

Address
Telephone
Email

3.  Qualifications, Training, Registration and Experience of Candidate

PLEASE NOTE: Applicants should complete only the relevant sections for the type of Lectureship they are applying for. Please refer to the Guidance for Applicants document.

(a)  Qualifications and Training Level of Candidates applying for a Clinical Lectureship

(I) For Nurses, Allied Health and Medical Professionals:

Please outline if you currently hold, or have recently submitted a thesis for, a PhD/MD/Prof Doc or equivalent qualification. This is mandatory to meet the eligibility criteria for application for a Clinical Lectureship.

Yes No

Please give details of date of submission of thesis or final award date where applicable:

(II) For Nurses and Allied Health Professionals Only:

Please outline if you have current registration with the Nursing and Midwifery Council (NMC), the Health Care Professionals Council (HCPC) and/or other relevant professional body? This is mandatory to meet the eligibility criteria for application for a Clinical Lectureship.

Yes No

Please give details of your current registration and any registration plans between now and the award date of March 2017:

(III) For Medical Professionals Only:

Please confirm that you are currently eligible for this award at training level ST4 or above?

Yes No

If no, please state if and when you expect to reach this level (it is mandatory for this to take place prior to March 2017 in order to be eligible for this award)

(b)  Qualifications and Training Level of Candidates applying for a Senior Clinical Lectureship or Reader (Clinical)

(I) For Nurses, Allied Health and Medical Professionals:

To apply for this award, you must hold a PhD/MD/Prof Doc or equivalent qualification. Please confirm you have obtained such a qualification and provide details and dates in the text box below.

Yes No

Please give brief details and date of qualification.

(II) For Nurses and Allied Health Professionals Only:

Please outline if you have current registration with the Nursing and Midwifery Council (NMC), the Health Care Professionals Council (HCPC) and/or other relevant professional body? This is mandatory to meet the eligibility criteria for application for a Senior Clinical Lectureship or Reader Award.

Yes No

Please give details of your current registration and any potential changes to this before March 2017:

(III) For Medical Professionals Only:

Has the candidate completed clinical training? Y/N / Specialty Area of CCT / Date of CCT, or due date of CCT

(c)  Qualifications and Experience of Candidates applying for a Non-Clinical Lectureship, Senior Non-Clinical Lectureship or Reader Award

Does the candidate hold a clinical qualification relevant to stroke? Y/N / Details of qualification and date on which clinical training was completed / Reason for leaving clinical practice (where applicable)

Please outline if you currently hold a PhD? This is mandatory to meet the eligibility criteria for application for Non-Clinical Lectureship/Senior Lectureship/Reader Awards.

Yes No

Please give brief details of PhD and award date:

Please outline the number of years of post-doctoral research experience you have to date, and give a brief summary of your current or most recent research position and its relevance to stroke research:

4.  Current and Previous Support of Candidate

(a) Is your position currently being supported by another funding body as a fellowship, lectureship or similar post?

Yes No

If yes, please give details of the funding award including the start and end dates:

(b) Have you held a previous fellowship, lectureship or similar post?

Yes No

If yes, please give details of the previous funding award including the start and end dates:

5.  Details of the Head of Department Nominating the Candidate at Host Higher Education Institute (HEI)

Surname / Forename(s) / Title / Position

2

Address
Telephone
Email

6.  Details of the Director, Vice-Chancellor, Principal or Dean at the Host HEI

Surname / Forename(s) / Title / Position

2

Address
Telephone
Email

7.  Details of the current Strategy of the HEI, and in particular, its relevance to stroke research where applicable (This statement should not exceed one side in length)

8.  Details of the current status and future plans of the HEI in supporting or capacity building in stroke research and/or related relevant disciplines (This statement should not exceed one side in length)

9.  Details of the NHS/Clinical Employer (Do Not Complete this Section if applying for a Non-Clinical Lectureship, Senior Lectureship or Reader Award)

Surname / Forename(s) / Title / Position

2

Address
Telephone
Email

10.  Address of the HEI Department where candidate’s research will be hosted

Address
Telephone

2

11.  Research Programme Title

12.  Abstract of Research (200 words max)

13.  Lay Research Programme Title

14.  Lay Abstract of Research (300 words max)

15.  Summary of requested support from the Stroke Association

Proposed Start Date:

Year 1 (£) / Year 2 (£) / Year 3 (£) / Year 4 (£) / Year 5 (£) / Total
Salary (Yours)
Equipment
Consumables
Salaries of Other Research Staff
Travel
Other expenses
Stroke Association Support Programme / £4,500 / £4,500 / £4,500 / £4,500 / £4,500 / £
Total Support Requested

16.  Support from elsewhere

Is your related research currently being supported by another funding body?

Yes No

If yes, please give details:

17.  Parallel submission

Are you currently applying for a fellowship, lectureship or other similar position elsewhere?

Yes No

If yes, please give details:

18.  Intellectual Property

Could the research in this application lead to the generation of a new product/process, or the generation of intellectual property?

Yes No

If yes, have you consulted your in-house technology transfer or IP liaison unit?

Yes No

Please give details:

19.  Have you involved a Research Design Service or Clinical Trials Unit in the design of the research application?

Yes No

If yes, please give details:

20.  Public and/or Patient Benefit and Involvement

a.  Please describe how the public and/or patients have been involved in the research to date and the development of this application:

b.  Please describe how the public and/or patients will be involved in this work:

c.  Please describe how the proposed research will have benefit for the public and/or patients affected by stroke:

d.  Please describe how you will disseminate the outcomes of the research to the public and/or patients:

21.  Research involving animals

If you are applying for research involving animals, you must answer these questions:

a.  Do your proposals include procedures to be carried out on animals in the UK under the Animals (Scientific Procedures) Act?
Yes No

b.  Have the following necessary approvals been given by:

·  The Home Office (in relation to personal, project and establishment licences)?
Yes No Not required

·  Animal Welfare and Ethical Review Body?
Yes No Not required

c.  Do your proposals involve the use of animals or animal tissue outside the UK?
Yes No

d.  Has the Home Secretary granted a project license under the terms of the Animals (Scientific procedures) Act 1986, authorising the proposed experiments?

Yes No

Please state the name and address of the licensee, the Home Office reference and the date of issue. Please attach a photocopy of the front page to your application.

d.  Do you or any other researchers associated with the project hold a personal license under the Animals (Scientific procedures) Act 1986, permitting the procedures required to be carried out?

Yes No

Please state the name and address of the licensee, the Home Office reference and the date of issue. Please attach a photocopy of the front page to your application.

e.  If your project involves the use of animals, what would be the severity of the procedures? Mild Moderate Severe

f.  Please provide details of any moderate or severe procedures (no more than 250 words)

g.  Why is animal use necessary; are there any other possible approaches? (no more than 250 words)

h.  Why is the species/model to be used the most appropriate? (no more than 250 words)

i.  Please justify the number of animals to be used per experiment, including details of any sample size calculations and/or statistical advice sought. Please also explain how the 3R’s (replacement, refinement and reduction) have been considered in the planning of this project?

22.  Previous Awards from the Stroke Association

a. Please list any previous funding from the Stroke Association that the host HEI has received within the past five years:

b. Please list any previous funding from the Stroke Association that the candidate has received within the past five years:

23.  Letter of Support from HEI

Has a letter of support been provided and attached to this application confirming that the relevant support is in place for this candidate to take up a lectureship/senior lectureship/reader position, and signed by the Head of Department and the Director, Vice-Chancellor, Principal or Dean of the HEI?

Yes No

Please note:

This is mandatory for all application submissions. Please see the Guidance for Applicants for required details that the HEI support letter should include.

24.  Letter of Support from NHS/Clinical Employer (for Clinical Lectureships, Senior Clinical Lectureship and Reader (Clinical) applications only)

Has a letter of support been provided and attached to this application confirming that the relevant support is in place for this candidate to take up a clinical lectureship/reader position, and signed by the NHS employer?

Yes No

Please note:

This is mandatory for a Clinical application submission. Please see the Guidance for Applicants document for required details that the NHS support letter should include.

25.  Declarations and Signatures

Please ensure you provide wet, original signatures on the original hard copy you provide.

Signature of Lectureship/Reader Candidate

Acceptance of Conditions of Award:

“I have read the Conditions of Award, and if this application is successful, I agree to abide by them. I have no obligations which would conflict with the Conditions of Award.”

Signed: Date:

Signature of Director, Vice-Chancellor, Principal or Dean of the HEI

Acceptance of Conditions of Award:

“I confirm I have read this application, and that if it is granted, the research will be accommodated and administered in accordance with the Conditions of Award. I agree to the statements in sections 28 and 29 and will ensure the Lecturer/Reader receives all the necessary support to undertake this position. Staff grading and salary are at an agreed level that will be guaranteed throughout the Lectureship/Reader Award. I have no obligations which would conflict with the Conditions of Award.”

2

Signed: Date:

Printed Name, Initials and Position of the above:

Signature of the Head of Department and the Finance or Research Administration Officer at HEI


The Head of Department and the Finance or Research Administration Officer should sign the following declaration:

“I confirm I have read this application, and that if it is granted, the research will be accommodated and administered in accordance with the Conditions of Award. I agree to the statements in sections 28 and 29 and will ensure the Lecturer/Reader receives all the necessary support to undertake this position. Staff grading and salary are at an agreed level that will be guaranteed throughout the Lectureship/Reader Award. I have no obligations which would conflict with the Conditions of Award.”

2

Signature of Head of Department: / Signature of Finance or Research Administration Officer:
Printed Name, Initials and Position of above: / Printed Name, Initials and Position of above:
Address (if different from Award Holder): / Address:

Signature of Research Sponsor

The NHS Research Governance Framework for Health and Social Care requires that all work covered by this proposal must be sponsored. The Stroke Association is unable to act as sponsor for the work it funds.

“I accept the responsibilities of research sponsor as defined by NHS Research Governance Framework for Health and Social Care for the research outlined in this award application.”

Signature of Sponsor: / Printed Name and Initials of Sponsor:
Address: / Position:
Organisation:
Tel: / Date:
Signature of NHS/Clinical Employer
(Applications for Clinical Lectureships, Senior Clinical Lectureships and Reader (Clinical) only)

Acceptance of Conditions of Award:

“I have read the Conditions of Award, and if this application is successful, I agree to abide by them. I agree to the statement in section 30 stating the clinical hours and the maximum on call/emergency hours that the candidate will commit to, and commit to ensure that this will not be exceeded during the course of this Lectureship/Reader Award. Staff grading and salary are at an agreed level that will be guaranteed throughout the Lectureship/Reader Award. I have no obligations which would conflict with the Conditions of Award.”

Signed: Date:

Printed Name, Initials and Position of the above:

26.  Proposed Research Programme by Candidate

Please refer to the Guidance for Applicants. The statement should not exceed 6 sides. One additional side (the seventh) may be used for references only, 9 sides of A4 are permitted including additional figures, tables and a timeline or Gantt chart, see Guidance for Applicants for more details on this. Please include details of the potential role of PhD/Post-Doc researchers or other research training positions that will be incorporated into this research plan.