PHD STUDENTSHIP

APPLICATION FORMver1.0

Please use the Guidance Notes when completing the application form

Section 1: Applicationsummary Details

Q1 (a) PRINCIPAL SUPERVISOR(Title / Name)
(b) SUBSIDIARY SUPERVISOR (Title / Name)
Q2. DEPARTMENT(S) IN WHICH RESEARCH WILL BE CARRIED OUT(name / location)
Q3. PROJECT TITLE (max 20 words)
Q4. HOST INSTITUTION (select one) / Moorfields Eye Hospital / UCL Institute of Ophthalmology
Q5. CATEGORY OF RESEARCH PROPOSED Please select either (a) or (b)
(a) Biomedical / Laboratory based research
(b) People/patient-based clinical or applied health research
ADDITIONAL INFORMATION
Will any part of this research project use animals or tissue, cells, serum etc derived from animals / Yes / No

Section 2: Summary of proposed research

Q1. AREA OF RESEARCH PROPOSED Select area(s) (max 2) that relate to the largest theme(s) of the proposal
AMD / Corneal / ocular surface disease / Community health / rehabilitation / patient support
Diabetic retinopathy / Glaucoma / Lens / cataract
Neuro-ophthalmology / optic neuropathies / Ocular cancer / Paediatrics
Ocular inflammatory diseases / Ocular motility / visual processing
Genetics / Inherited eye disorders / Retinal / Vitreo-retinal
Q2. JOINT MEH/IoO RESEARCH STRATEGYPlease select one from (a) and (b) as applicable
(a) Disease / Glaucoma / AMD / Diabetic retinopathy / Inherited eye disease / rare diseases
(b) Treatment / approach / Cell therapy / Informatics / Imaging / Gene therapy
Other (max 100 words)
Q3. SUMMARY FOR LAY READERS (Please refer to guidance notes before completing this section. max 150 words)
Q4. SUMMARY OF PROPOSED RESEARCH FOR SCIENTIFICALLY QUALIFIED ASSESSORS (To include key research question(s), aims & objectives - max 150 words)
Q5. STRATEGIC FIT AND ENHANCEMENT OF RESEARCH AND CLINICAL PRACTICE(max 150 words)
Q6. IMPACT STATEMENT(max 150 words)
Q7 OTHER SUBMISSIONS
Has the proposed project been submitted, or is it going to be submitted, to another funding body?
If ‘YES’, provide the following information for each submission: Funding body, date of submission, date outcome known, outcome (if known)

Section 3: PRINCIPAL SUPERVISOR DETAILS

Q1.CONTACT INFORMATION
Name and Title
Current post(s)(include employer name)
Start and enddates of primary contract
(mm/yyyy - to - mm/yyyy) / - to -
Address (department name and location)
Email address / Contact telephone number
Time spent on research (hrs per week) / Time spent on this grant (hrs per week)
Q2. Have you directly supervised a PhD student before? / Yes / No
If yes, please indicate number / as Principal Supervisor / as Subsidiary Supervisor
Of these students, how many have completed their PhD to date?
Q3. Do you have UCL supervisory approval?
To be Principal Supervisor / Yes / No / To be SubsidiarySupervisor / Yes / No
Q4. PREVIOUS POSTS HELD (most recent first, maximum 3 entries)
Date from mm/yyyy / Date to mm/yyyy / Position / Organisation
Q5. EDUCATION AND TRAINING (most recent first, maximum 3 entries)
Date awarded mm/yyyy / Qualification / Subject / Organisation
Q6. AWARDED GRANTS
Please list grants (most recent first) held in the last five years or any key prior grants. State name of awarding body, title of project, role on the grant (e.g. PI, Co-PI), amount awarded, and start/end dates.
For Special Trustee or Moorfields Eye Charity grants, please provide grant reference
Q7. PUBLICATIONS
Please list up to 5of your publications(including original research publications and other scholarly contributions) of relevance to the proposed project. Publications should be in chronological order with the most recent first.

Section 4: SUBSIDIARY SUPERVISOR DETAILS

Q1. CONTACT INFORMATION
Name and Title
Current post(s) (include employer name)
Start and enddates of primary contract
(mm/yyyy - to - mm/yyyy) / - to -
End of contract date (if applicable) (mm/yyyy)
Address (department name and location)
Email address / Contact telephone number
Time spent on research (hrs per week) / Time spent on this grant (hrs per week)
Q2. Have you directly supervised a PhD student before? / Yes / No
If yes, please indicate number / as Principal Supervisor / as Subsidiary Supervisor
Of these students, how many have completed their PhD to date?
Q3. Do you have UCL supervisory approval? Please refer to guidance notes
To be Principal Supervisor / Yes / No / To be Subsidiary Supervisor / Yes / No
Q4. PREVIOUS POSTS HELD (most recent first, maximum 3 entries)
Date from mm/yyyy / Date to mm/yyyy / Position / Organisation
Q5. EDUCATION AND TRAINING (most recent first, maximum 3 entries)
Date awarded mm/yyyy / Qualification / Subject / Organisation
Q6. AWARDED GRANTS
Please list grants (most recent first) held in the last five years or any key prior grants. State name of awarding body, title of project, role on the grant (e.g. PI, Co-PI), amount awarded, and start/end dates.
For Special Trustee or Moorfields Eye Charity grants, please provide grant reference
Q7. PUBLICATIONS
Please list up to 5 of your publications (including original research publications and other scholarly contributions) of relevance to the proposed project. Publications should be in chronological order with the most recent first.

Section 5: Details of Research Project

A scientific research proposal must be provided for all applications
Please answer each of the questions below as relevant to the proposed research question.
Images/figures/schematics may be embedded in the text or submitted as part of an appendix (maximum 2 sides of A4) to this section.
Protocols: It is NOT appropriate to submit a full standard protocol and instead all necessary information should be presented in this application form. For epidemiology, demographic, case control cohort and related studies or any clinical trial, give a full and detailed analysis of the study design, including details of any validation already undertaken or rationale for using standard protocols. Particular attention should be given to power calculations, sample size justification and where appropriate, case definitions and inclusion/exclusion criteria.
Q1. AIMS AND OBJECTIVES Max 200 words
Q2. BACKGROUND TO PROPOSED PROJECT Max 3000 words
Q3. EXPERIMENTAL DESIGN AND METHODS Max 650 words
Q4. STATISTICAL INFORMATION / CONSIDERATIONSMax 500 words
Q5. MILESTONES
Please include(as bullet points belowOR Gantt chart) attached to application)
  • Research objectives, dates they should be achieved
  • Possible publications (journal and submission dates), presentations / conferences, outcomes / innovations for clinical use
  • PhD progress reports and thesis submission deadlines

Q6. RESEARCH OUTCOMES AND CLINICAL BENEFITMax 500 words
Explain how achieving the research objectives will benefit patients, either as a direct result of your findings, or to inform future research that may result in clinical benefit. Include details of how expected outcomes will be evaluated
Q7. REFERENCES
Must be included – give full citation including title, journal title and list all authors (use of el al is only appropriate where there are >10 authors)

SecTion 6: RESEARCH AND TRAINING PROVISIONS

Q1. LOCATION(S) WHERE THE RESEARCH AND TRAINING WILL TAKE PLACE Max 300 words
Give details of the research environment(s), including special facilities and available expertise (beyond that of the supervsors and their teams) of relevance to the project
Q2. OUTLINE FOR EACH OF THE FOLLOWING (max 100 word for each section)
(a) Any (if known) research and generic/transferable skills training to be provided as part of this PhD Studentship
(b) How student progress will be supervised
(c) How student progress will be assessed

SecTion 7: Data Management and Sharing

DATA MANAGEMENT AND SHARING (max 300 words
Where appropriate, detail (a) your plans for data management, curation and storage (b) your policy for sharing data with others, including the management and prioritisation of access to data (c) your strategy for current and future communication with user communities and (d) any ethical considerations
Please refer to the guidance notes for additional advice

Section 8: Budget Details and Justification

ANNEX A – PhD BUDGET FORM
This excel file must be completed for each application and listed costs must correspond to the justifications provided below. Please refer to the guidance notes for details of how to correctly complete this annex.
All costs must be justified and described with respect to the proposed project
MATERIALS AND CONSUMABLES (max 300 words)
MISCELLANEOUS COSTS (max 200 words)
ACCESS CHARGES (TO EQUIPMENT/RESOURCE/FACILITY) (max 200 words)
ANIMALS (max 200 words)

Section 9: Additional information

Q1. ETHICAL APPROVAL
Does this project require ethical approval (NHS, HRA and/or Home Office)? (delete one) / Yes / No
Is this project a/part of a R&D non-commercial research study for which MEH will be sponsor? (deleteone) / Yes / No
Has this project been submitted for ethical approval (delete one) / Yes / No
If YES, by whom and when were the ethics of the project approved (include relevant reference number(s)).
If NO, by whom and when will the ethics of the project be considered
If this project is considered to be covered by existing ethical approval from a different project please confirm that new ethical approval is NOT needed (include relevant reference number(s)) and explain why existing ethical approval covers the project in this application (max 100 words)
Q2. NIHR CLINICAL RESEARCH NETWORK (CRN) PORTFOLIO
(a). Will this project have national ethics approval? (delete one).
If YES, please provide details... If NO please provide details of how/when this will be secured / Yes / No
(b)WillthisprojectbeadoptedontoaNIHRportfolio? (deleteone) / Yes / No
(c)Ifthisprojectisregistered,pleaseprovidetheportfolionumber
(d).IfthisprojectisNOTregistered,pleaseprovideexactdetailsofhowyouwillensureregistrationcanandwillbesecured.
Q3. RESEARCH INVOLVING ANIMALS
Will your project involve use of animals?(delete one) / Yes / No
If YES, please complete ANNEX C
Q4. INTELLECTUAL PROPERTY (IP) / COMMERCIALISATION
Will the proposed research use technology, materials or other invention that, as far as you are aware, are subject to any patents or other forms of intellectual property protection? If YES, give details (max 200 words) / Yes / No
Is the proposed research, in whole or part, subject to any agreements with commercial, academic or other organisation? If YES, give details (max 200 words) / Yes / No
Is there any potential for patents or commercially exploitable results from this research? If YES, give details (max 200 words) / Yes / No
If any potentially commercially exploitable results may be based upon tissues or samples derived from human participants, please confirm that there has been / will be appropriate informed consent for such use / Yes / No
If this research is successful will it provide added value e.g. new tools, drugs, biological materials, methods of treatment etc. that add value to eye health through a product, drug, vaccine etc. that should be protected because it will make money for the owner? If YES, please describe what this added value is (max 200 words)

Section 10: Principal Supervisor Sign Off

By signing this section, the Principal Supervisorconfirms that he/she have complied with the instructions for completing and submitting this application and if the application is funded he/she will agree to the terms, conditions and processes of the Special Trustees
Q1.CONSULTANCIES, EQUITIES AND DIRECTORSHIPS
Do you have consultancies or any equity holdings in, or directorships of, companies or other organisations that might pose a conflict of interest to the current application? If YES, give details (max 100 words) / Yes / No
Q2. PRINCIPAL SUPERVISOR SIGN OFF
Name (typed)
Signature(electronic)
Date (dd/mm/yyyy)
Q3. EXTERNAL PEER REVIEW
(a) Proposed external peer reviewers. Please provide the names and contact details (address and email address) for 3 potential external reviewers. These must not include colleagues from your organisation or those with whom you have published/collaborated with in the last 3 years
The Charity may or may not choose to approach some, or all, of the individuals you have selected
Reviewer 1
Reviewer 2
Reviewer 3
Reviewer 4
(b) Peer review restrictions. If you do not wish the Charity to approach certain people or institutions, please provide the name / details below

ANNEXB: Collaborator Form

Aseparateformshouldbeduplicatedforeachcollaborator/collaboratinggroup. Collaborators,in this context,arescientific/medical/academiccolleagueswhoareassociatedwitharesearchproposalandnamed inthebodyoftheapplicationbutwhoarenotco-applicants.Theyarenotusuallyinvolvedintheday-to-day runningoftheprojectforanylengthoftimeandusuallycontributeexpertiseormaterialtowardsadiscrete pieceofworkontheproject.
PRINCIPAL SUPERVISOR(name/title)
PROJECT TITLE
COLLABORATOR DETAILS
Name and Title
Address (department name and location)
Email address
Role/contributiontotheproject(max100words)
Please indicate if there are any Intellectual Property issues or restrictions arising from Material Transfer Agreements (max 100 words)
COLLABORATOR
Name (signature*)
Date (dd/mm/yyyy)

*electronic signature is sufficient

ANNEXC: ADDITIONALINFORMATIONFORRESEARCHINVOLVINGANIMALS

Pleasecompleteandattachtoapplicationiftheproposedresearchwillinvolveanimalsand/oranimaltissue
Q1. Will your project be governed (fully or in part) by the provisions of the Animals (Scientific Procedures) Act of 1986? / Yes / No
Q2. Will your project include procedures to be carried out on animals in the UK which require a Home Office licence? / Yes / No
If YES, please give details of why animal use is necessary, how you have considered the three Rs (Replacement, Reduction and Refinement) details and why other possible approaches are not used (max 200 words)
Q3.PleaseverifythatthenecessaryHomeOfficeprojectandpersonallicensesareinplaceandprovidethelicencenumber. / Yes / No
IfNO,pleaseexplainwhy.
Q4. As part of this project, will experiments be carried out on animals outside of the UK / Yes / No

ANNEXD–research office approval

  • All applications must be approved by MEH R&D office even if all the research (and costs) will be carried out at UCL Institute of Ophthalmology (IoO).
  • Signatures must be signed and not typed and the completed page scanned and submitted as a PDF/TIFF file. A copy of an email confirming approval from the appropriate representative will suffice but a copy must accompany the application when submitted
  • Applicants who have selected IoO as the host institution must ensure this Annex is signed by MEH R&D office (Q2) before they submit their application to the IoO Research Office for approval

To be completed by the Applicant prior to seeking r&D approval

Will proposed research use facilities / patients at MEH?(tick one) / Yes / No
Will costs be incurred at MEH? (tick one). If YES, Q1 must be signed / Yes / No

To be completed by the MEH r&D / UCL Institute of ophthalmology research office REPRESENTATIVES

We,theundersigned,confirmapprovalforsubmissionofthisapplicationonthebasisofthecostsoutlinedintheattachedapplicationWeindicatebelowanyconditionsattachedtoourapproval.Weunderstandthatifthisapplicationforfundingissuccessful,theprincipalhostinstitution(asnamedinSection1)willberequiredtoconfirmacceptanceoftheSpecialTrusteesterms,conditionsandreportingprocesses.Weagree,wherewerepresentcollaborateinstitutionstoprovideinatimelyfashion,anyinformationrequiredbytheSpecialTrusteesortheprincipalhostinstitution.
Q1.MOORFIELDS RESEARCH FINANCE REPRESENTATIVE APPROVAL
Name {signature) / Date (dd/mm/yyyy)
HaveyoureviewedAnnexA-Budget(excelfile)forthisapplication? (tickone) / Yes / No
Doyouapprovethisapplication?(tick one) / N/A (no MEH costs) / Yes / No
Comments/Conditions
Q2.MOORFIELDS RESEARCH & DEVELOPMENT OFFICE REPRESENTATIVE APPROVAL
Name {signature) / Date (dd/mm/yyyy)
Doyouapprovethisapplication?(tick one) / N/A (no MEH component) / Yes / No
Comments/Conditions
Q3. UCL INSTITUTE OF OPHTHALMOLOGY RESEARCH OFFICE REPRESENTATIVE APPROVAL
Name {signature) / Date (dd/mm/yyyy)
Doyouapprovethisapplication?(tick one) / Yes / No
Comments/Conditions

PS/08/2015/VER1.01