Health Professional Scholarship

Application Form

  1. Project Title

Simplified Project Title: / (100 characters max) / Research Category:
Scientific Project Title: / (300 characters max) / Click hereBiomedicalClinicalPublic HealthHealth Services
  1. Applicant Details

Title: / Click hereMsMrsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline: / Mobile:
Gender / Click here MaleFemalePrefer not to say
Email:
Position: / Institution type:
Position Start Date: / mm/yyyy / Current Salary ($) / FTE: / Click here1.0 FTE0.9 FTE0.8 FTE0.7 FTE0.6 FTE0.5 FTE0.4 FTE0.3 FTE0.2 FTE0.1 FTE
I am an Australian or New Zealand Citizen (attach a birth certificate or passport to Q27).
I am an Australian Permanent Resident (attached permanent resident certificate or evidence of submission for Australian Permanent Residency to Q27).
Click here NeitherAboriginalTorres Strait IslanderBothPrefer not to say / Are you of Aboriginal or Torres Strait Islander descent?
  1. Administering Institution Details
Please ask permission before including other people’s personal information. The Privacy Statement at the end of this document should also be noted
Institution Name: / Address:
ABN: / Suburb: / State: / Postcode:
Research Office:
RAO Contact Person: / Title: / Click hereMsMrsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline: / Email:
Mobile:

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  1. Supervisor Details
Please ask permission before including other people’s personal information. The Privacy Statement at the end of this document should also be noted
Title: / Click hereMsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline: / Mobile:
Gender / Click here MaleFemalePrefer not to say
Email:
Position: / Current Institution:
  1. Project Synopsis /Potential Outcomes

Using lay terms, describe the overall aims of the research and expected cardiovascular health outcomes. Avoid technical terms. Your answer should be suitable for release to media and general publications.
(1500 characters maximum)

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  1. Ethics Type

Is Ethics Required? Please select Ethic requirements associated with your research. All ethics approvals and clearances necessary to complete the project outlined in this application must be forwarded to the Heart Foundation within 30 days of approval.
Select all Ethic requirements associated with your research:
No Ethics Required
Human Ethics
Animal Ethics
Biosafety Clearance
Other Ethics Type
If any of the approvals above are not required in order to commence the proposed work, please detail the reasons why and indicate the date when the ethics clearances will be required.
(800 characters maximum)

Application Details

  1. Health Professional ScholarshipStart Date

Project Start Date: / Click here1st January 20181st April 20181st July 2018 / Nominated FTE rating: / Click here1.0 FTE0.9 FTE0.8 FTE0.7 FTE0.6 FTE0.5 FTE
  1. PhD Status

I have commenced my PhD / Course start date: / dd / mm/yyyy / Full Time Equivalent (in Months): / Click here123456789101112
If you have commenced your PhD, indicate the period of full-time enrolment, in calendar months, up to the closing date of application.
If you have completed the equivalent of more than 1 year of your PhD at 1.0 FTE at the closing date of application, you are ineligible to apply (e.g. 1 year @ 1.0 FTE = 2 years @ 0.5 FTE).
I have not commenced my PhD / If you have yet to enrol in a PhD, a signed letter from your administering institution indicating that you are in the process of enrolling for a PhD should beprovided in Q28.
  1. Other Funding

Do you currently hold a PhD Scholarship? / Yes / No
If you do currently hold a PhD Scholarship, please provide brief details below including start and end dates of the scholarship as well as the scholarship name and provider.
Scholarship Name:
Scholarship Start Date: / dd / mm/yyyy / Scholarship End Date: / dd / mm/yyyy
Scholarship Provider:
Have you applied, or do you plan to apply, for a Scholarship to conduct similar research from any other funding body in 2017?
Funding Body: / Details:
Include award type, name, category and reference/application number if known

TRACK RECORD

  1. Summary of Qualifications
List your three most relevant qualifications.
Year / Qualification Name
(300 characters max) / Educational Institution
(300 characters max)
yyyy
yyyy
yyyy
  1. Current Position

Position:
(300 characters max) / Employer:
(300 characters max) / Position start Date:
mm/yyyy
  1. Previous Appointments
In order of most recent
Position:
(300 characters max) / Employer:
(300 characters max) / Dates:
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
mm/yyyy-mm/yyyy
  1. Awards / Achievements
List your top five awards or achievements. Awards should include description of award / achievement, provider of award / achievement and award / achievement year
Award / Achievement:(500 characters max) / Date:
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
  1. Cardiovascular Health Practice

Supply details of your track record in cardiovascular health practice. Please ensure that the relevance of your work to cardiovascular health is clear.
(1000 characters maximum)
  1. Research Involvement

Have you had any previous involvement in research? If so please briefly describe this involvement.
(1000 characters maximum)
  1. Motivation

Why do you wish to undertake a PhD at this time in your career? What are your overall career aspirations?
(1000 characters maximum)

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  1. Publications

Include publications that have been published, or accepted for publication, in refereed journals (maximum 30). Do not include conference abstracts or submitted publications that have yet to be accepted. The list must be numbered and each reference should include below fields. Please add impact factors and citations for each publication as well as the relative ranking or importance of each journal within its field (if available).
Number / Applicant author status / Further reference details: Publication title, Authors, Journal Title, Publication year, Volume, Page Number, Citations, Link to Publication
1 / Click here First authorLast authorMiddle author
2 / Click here First authorLast authorMiddle author
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4 / Click here First authorLast authorMiddle author
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29 / Click here First authorLast authorMiddle author
30 / Click here First authorLast authorMiddle author
  1. Presentations

Include presentations at international, national, state and local conferences that were given (maximum 30).The list must be numbered and each reference should include below fields.
Number / Presentation Type / Presentation – Invited? / Further presentation details: Title of presentation, Conference name, Location: (International/national/state/local), Date.
1 / Click here OralPoster / Click here YesNo
2 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
3 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
4 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
5 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
6 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
7 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
8 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
9 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
10 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
11 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
12 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
13 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
14 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
15 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
16 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
17 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
18 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
19 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
20 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
21 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
22 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
23 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
24 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
25 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
26 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
27 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
28 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
29 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo
30 / Click here Oral PresentationPoster PresentationOther Presentation / Click here YesNo

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Purpose of Award

  1. Continued Cardiovascular Health Practice

How do you intend to continue your cardiovascular health practice during your PhD?
(2500 characters maximum)

Research Proposal

  1. Project Plan Summary

Provide a brief summary of your project plan.
(1000 characters maximum)
  1. Aims and Hypothesis

Summarise the Aims of your project and your Hypothesis.
(1000 characters maximum)
  1. Relevance to Cardiovascular Health

Indicate the relevance and impact of your project to cardiovascular health.
(1200 characters maximum)
  1. Research Environment

Briefly summarise the research environment including quality/experience of supervision, international standing of lab, facilities, infrastructure and funding that is available to support your proposed research
(1000 characters maximum)

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  1. Research Plan and Figures

Research plans are limited to 8,000 characters (including spaces)(also including no more than 15 references) and must be completed using Arial 12 point font. Do not alter page layouts, borders, page or section breaks or any other formatting. Plans must start under this header. All documents not adhering to these guidelines will be reformatted and any additional information exceeding two pages will be automatically deleted. Documents significantly deviating from these guidelines will not be considered further.

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When preparing your research plan, please include Background, Methods and References sections (this sentence may be deleted).

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Referee Endorsements

  1. Referee 1
    Please see our Privacy Statement at the end of this document

Do not exceed this page
Referee Details
Title: / First Name: / Last Name:
Email:
Position:
Institution:
Please describe your relationship with this referee? (3 lines maximum)
  1. Referee 2
    Please see our Privacy Statement at the end of this document

Do not exceed this page
Referee Details
Title: / First Name: / Last Name:
Email:
Position:
Institution:
Please describe your relationship with this referee? (3 lines maximum)

Evidence of Citizenship

  1. Evidence of Citizenship

Insert evidence of citizenship, permanent residency (or application for permanent residency) below Two pages maximum including this page.

Insert here

Evidence of PhD Enrolment

  1. Evidence of PhD Enrolment

Insert evidence of PhD Enrolmentbelow. If you have yet to enrol in a PhD, a signed letter from your administering institution indicating that you are in the process of enrolling for a PhD should be inserted below. Two pages maximum including this page.

Insert here

Endorsement

Applicant and Supervisor
I certify that all details provided in the Fellowship application (including annexures) are correct and that I have read, understood, and have abided by the instructions associated with this form.
I agree to carry out the project in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007). I acknowledge that all ethics approvals and clearances necessary to complete my project as outlined in this application will be in place before commencement of the work.
By signing, I confirm that I have complied with all instructions in the application form and understand that failure to do so may result in the withdrawal of the application from the review process.
I also acknowledge all supporting documentation has been provided with this application. I understand that my application will not be eligible for consideration by the Heart Foundation if this application is incomplete or lacking the required documents.
Please see our Privacy Statement at the end of this document
Title: / First Name: / Last Name:
Date: / __/__/2017
Title: / First Name: / Last Name:
Date: / __/__/2017
Verification by Research Office
I, a representative of the Institution’s Research Office, verify that I have checked this application and that to the best of my knowledge, all instructions included in this form have been complied with and all relevant details are correct at the time of lodgement with the Heart Foundation. In addition, I verify that this institution has established administrative procedures for assuring sound scientific practice in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007).
Please see our Privacy Statement at the end of this document
Title: / First Name: / Last Name:
Email: / Landline:
Position:
Institution Name:
Date: / __/__/2017

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Privacy Statement

Your Personal Information is being collected by the Heart Foundation in order to assess your application for this grant. If you are not successful in your application we will retain your application on file indefinitely . We respect your privacy and embrace the principles contained in the Privacy Act. The Heart Foundation (we, us, our) is the National Heart Foundation of Australia and all associated Australian State and Territory Heart Foundation Divisions, full details of which can be found in our Privacy Notice.

If you do not want to receive further communication from us (other than information that relates to this application) or if you have any questions about privacy please contact the Research Program at or call (03) 9321 1581. Our APP privacy policy is set out in our Privacy Notice and details how you may complain about privacy issues and how we would deal with that complaint. It also explains how you can access, correct or update information we hold about you. A copy of our Privacy Notice is available at or on request. [HFPS06-140410-F]

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