HRC Ref ID: 15/xyzFirst NI: surname
Partnership Programme Request for Proposals
Pertussis Vaccine (JV215-PTV)
Coversheet
HRC Ref ID#:Click here to enter HRC Ref ID#
NI:Click here to enter surname.
Computer used to complete this form:Click here to enter Windows or Mac.
This COVERSHEET is for identification purposes. It will be replaced by the online pages in the final submitted application compiled by the HRC Gateway (
Enter the details above before going to page 2.
When completed, save this form as a pdf file before uploading to the HRC Gateway. In the pdf version of this document, Module 2 must begin on a new page.
Use only Arial 10 point or 11 point type when completing this form.
Double-click the second page header, replace “surname” with the first named investigator’s surname and add HRC Ref ID. Double-click elsewhere on the form to return to main part of form.
Before completing this application form, applicants are advised to:
1)Read the Partnership Programme Application Guidelines for the Pertussis Vaccine RFP for information on completing this form
2)Read the HRC Rules for applicant eligibility criteria and budgetary entitlements
3)Confirm the application due date for electronic files and hardcopies
4)Ensure that the correct version of this application form is used.
Incomplete or late applications will not be accepted.
MODULE 2. PROPOSED RESEARCH
Section2A – Summary of Proposed Research
There is a 1 page limit for this section. Use the headings provided.
Rationale for research
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Relevance to RFP
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Aims
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Research design and methods
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Main outcome measures
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Section 2B – Description of Proposed Research
There is a 8 page limit for this section. Please address all of the following points. The assessing committee will use responses under the headings to form a judgement about the merit of the proposal. Provide an appropriate balance of information and a convincing case for achievement.
You may delete instructions under each heading before writing
Rationale for research
Include information that you feel is essential for the reader of the application to better appreciate or understand the rationale for your research application. Why is the issue being approached in the way outlined in this application?
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Relevance to RFP
The relevance and contributions of this research application to the aims and objectives of the RFP must be clearly expressed. For example, what is the significance and contribution of the research to this research field; where relevant, how could the research impact upon health policy and/or the provision of health services? Rather than wasting valuable space with large amounts of background information on the general health problem, focus on how your research will contribute to address the problem and/or develop new knowledge.
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Research design and methods
Include your specific research hypothesis (if relevant), and a detailed design that describes sample recruitment and characteristics (including number, gender and ethnicity where relevant), study methodology, and proposed methods of data analysis. Where appropriate, provide an estimate of the likely effect size and the sample size required to detect this (power analysis). Consultation with specialists such as methodologists, statisticians and health economists before finalising your research design is recommended. It is important that you consider how the research design and methods will meet the requirements of the RFP and ensure the delivery of any outputs as stated in the RFP.
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Responsiveness to Māori
How might your research contribute to the health needs of Māori? What is the health significance and context of this research to Māori? Discuss the incidence or prevalence in Māori, or indicate if not known to be significantly different from the general population. Have you sought advice for the study from a Māori researcher/representative (if applicable)? Note: The declaration on Responsiveness to Māori, which forms part of the Administrative Agreement with the host institution, is in Section 6B.
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Dissemination strategy
Provide full details of your proposed dissemination strategy. As all partnership programme initiatives are designed to contribute to an evidence base for policy and practice this should include how the research results will be appropriately disseminated to the following end-users: Policy-makers, professional colleagues, health service funders and providers, the general public, study participants, iwi and other important groups.
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Track record of the research team relevant to this proposal
Use this section to discuss your current or previous related research and outline the outputs and outcomes from that research, to demonstrate the ability to deliver the proposed study outcomes in response to the RFP. If the research in this application arises directly from research undertaken on previous research contracts, please provide a statement of the original aims and objectives of those contracts and the degree to which these were met. If the research did not progress as anticipated, provide explanations.
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MODULE 3. REFERENCES
There is a 1 page limit for this section.
MODULE 4. CONTRACT INFORMATION AND BUDGET
Use the HRC Excel Spreadsheet‘JV215-Budget.xls’ for Sections 4A – 4D.
For the hardcopy of the application:
Attach a printout of the spreadsheet Sections 4A-4D (Contract Information (Objectives and Milestones), Budget, MoU Budget(s) and FTE Summary) after this page of the application form.
Ensure any page breaks are logically placed to facilitate review.
For the electronic copy of the application:
Upload the Excel andpdf file to HRC Gateway using the required file format.
Section 4E – Justification of Expenses
Justification of Research Staff (as listed in budget)
Justify the role of all staff (named and un-named). Unnamed postdoctoral fellows should also be justified here. Please note that unnamed PhD students will be disallowed. “Staff” may include research assistants, technicians, medical staff, interviewers, support staff or similar, whose names or position titles are listed in the budget under “Research Staff” and who have specific FTE involvements. Clearly state if staff will be promoted during the project, or the annual salary inflation will automatically be capped to 3%.
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Justification of Working Expenses and Casual Staff (as listed in budget)
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Section 4F – Previous/Current contracts
List previous / current contracts awarded within the past 5 years. Final HRC reports may be made available to the Assessing Committee.
Copy and paste additional tables if required.
Funding agency::Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #), was Final Report filed? If not, why?
Funding agency::
Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #), was Final Report filed? If not, why?
Funding agency::
Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #), was Final Report filed? If not, why?
Funding agency::
Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #), was Final Report filed? If not, why?
Section 4G – Other Support
Other Research Applications Awaiting Decision
List other research applications awaiting decision (including those to the HRC). Applicants must advise the HRC of the outcome of other research applications through their Research Office. Copy and paste as required for additional pending applications.
Funding agencyTitle of research
Named investigators
Start date and duration
Total value
Date of outcome
Areas of overlap with this Application, HRC Ref#?
Funding Agency
Title of research
Named investigators
Start date and duration
Total value
Date of outcome
Areas of overlap with this Application, HRC Ref#?
Co-Funding
What other agencies or end-users have been approached or committed to joint or partial funding of this research?
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Financial Interest(s)
Do you or any named investigator have a financial interest related to the research or sponsorship of the research?
Yes / NoFinancial interest?
If yes, outline below and provide details of your conflict management strategy.
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Section 4H – Letters of Collaboration/Supporting Documents Index
Please list below all memoranda of understanding or subcontracts, and letters of collaboration which outline material or actual support and supporting budget documents. Refer to the Guidelines for instructions about how to attach these documents.
Peer Reviewers and Assessing Committee members will see the list below and documents will only be made available on request.
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List of Collaborators (National and International)
Please list all collaborators associated with this project
Collaborator Name / Organisation / Country / Purpose / Support (NZ$ or in-kind)MODULE 5. NZ STANDARD CV
Please paste the CVs for all staff that will contribute to this research.
Please ensure that all named CVs are identical to those entered in the online form or the application may not be processed.
CV guidelines must be followed: no more than 2 pages for Part 1; 3 pages for Part 2; Arial 12-point font; standard margins; deleted instructions. List publications with full authorship.
MODULE 6. ADMINISTRATION
For HRC Partnership Programme applications, Module 6 is required to be completed, signed and included as part of the hard copy of the application (send with original application only).
Section 6A – Ethical and Regulatory Agreement
First Named InvestigatorResearch Title
Yes / No / Ethics Committee
Requires human ethical approval?
Copy of current human ethical approval attached?
Requires animal ethical approval?
Copy of current animal ethical approval attached?
If this application does not require ethical approval, please briefly provide reason;
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If this application requires consent from other regulatory bodies such as ERMA, MAF, DOC, GTAC, SCOTT or Biosafety, please provide reason;
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The following information will be used for administrative purposes.
Yes / No1. Is the proposed research a clinical trial, a community intervention study or innovative treatment?
2. If yes to the above, do you intend to have an Independent Data Monitoring Committee?
Note: Please refer to Guidelines for application forms for information about role of independent DMCs and description of HRC DMC processes. For further information please contact the Secretary to the DMCC, .
First Named Investigator
Name: / Signed: / Date:
Head of Department/School/Faculty or Hospital
Name: / Signed: / Date:
Section 6B – Administrative Agreement
Only one signed copy of this page is required. This form must be returned to the HRC with the original copy of the contract application.
Applications with an incomplete administrative agreement will not be accepted.
All HRC applications must include an undertaking to abide by the following administrative agreement:1.It is understood and agreed that this application and any contract awarded as a result of this application is subject to the Health Research Council of New Zealand Rules (“Permissible Use of Research Funding and Operation of Contracts”). Funds will not be expended for any other purpose than described in this application.
2.The host institution agrees and undertakes to bear all risk and claims connected with any operation covered by this application and to indemnify and hold harmless the Council against any and all liability suits, actions, demands, costs or fees on account of death, injuries to persons or property, or any other losses resulting from or connected with any act or omission performed in the course of the research.
3.The host institution agrees and undertakes to support for the duration of any contract, the work described in this application by making available accommodation, basic facilities for research and the services necessary for its fulfilment.
4.The Head of Department agrees to accept this research within his/her department if a contract is made, agrees to provide workload relief for research staff working on this contract (Principles of Full Cost Funding), and is aware that s/he may be requested by the HRC to provide a confidential assessment of the research during the term of the contract.
5.The host institution official designated below agrees to ensure that the research will have been approved, where necessary, by the appropriate institutional biosafety committee and/or all other required regulatory agencies before research is commenced.
6.The applicant(s) agrees to allow specified personal information to be used for statutory and publicity purposes.
7.The host institution has in place policies and processes to ensure that consultation with Maori has occurred and the application is responsive to the needs and diversity of Maori.
We the undersigned have read the above administrative agreement and undertake to abide by the conditions of this agreement in respect of any contract made by the Health Research Council of New Zealand as a result of this application. We the undersigned confirm that the information provided in this application is to the best of our knowledge true, that all sections are correct at the time of application submission, that each NI agrees to the stated FTE% contribution and that funding to any NI from any source will not exceed 100 FTE%.
First Named Investigator
Name: / Signed: / Date:
Head of Department/School/Faculty or Hospital
Name: / Signed: / Date:
Authorised official on behalf of host institution
Name: / Signed: / Date:
Position: / Host name:
MODULE 7. CLASSIFICATION OF RESEARCH
Do not copy any sections in Module 7. Send with original application only.
Section 7A – Australian and New Zealand Standard Research Classification (ANZSRC)
This Module is for evaluation purposes only and is mandatory; incomplete applications will not be processed.
Applicants are required to categorise their research using the ANZSRC codes. A maximum of 3 for Fields of Research and a maximum of 3 for Socioeconomic Objective classifications found on the HRC web link ( – find the appropriate 6-digit code(s) and description and enter both code AND description(s) below. Weighting % entered to nearest 10% and totals to 100%.
Research DescriptorsFields of Research (FOR) / Weighting (%)
Socioeconomic Objective (SEO) / Weighting (%)
Keywords
Section 7B – Economic Benefits
This information is required for reporting to government and so is mandatory. Incomplete applications will not be processed.Describe the economic benefits that may arise from the research, or state if the economic returns will accrue from health benefits. If no direct economic benefits are anticipated, please state this rather than leaving the field blank.
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JV215-PTVApplication form © 2014 Health Research Council of New Zealand. All rights reserved. 1
In Confidence