Faculty of Biology, Medicine and Health

Faculty of Biology, Medicine and Health

6-Month Clinical Pump-Prime Award

Application Form

Part A: The Applicant

Surname / Correspondence Address:
Forename
Title:
Tel No:
Email:
Current employer: / Postcode:

Curriculum Vitae including undergraduate/postgraduate achievements, prizesand publications
Please attach separately, maximum 2 pages.

Statement on career intentions including why you want to undertake research(max 200 words)

Research experience to date (max 200 words)

A5 Contact details of 2 academic or professional referees

References: Name and full postal address and email address of persons to whom reference may be made.
Name / Name
Postal
Address / Postal
Address
Email / Email

Part B: You proposed 6-month research project

Title of proposed research project

Abstract: please detail the hypothesis, aims, methodology, and the potential scientific and medical outcomes (max 300 words)

Research to be undertaken(Maximum 2 sides of A4, minimum font size 11, standard margins, excluding references)
Please insert separately

a. Why and how will this 6-month project ‘pump-prime’ external applications for a Clinical Research Training Fellowship? i.e. bids for a three-year out-of-programme fellowship leading to a PhD from the MRC, Wellcome Trust, NIHR or AMRC member (i.e. BHF,ARUK etc). Maximum of 300 words.
b. Please list your proposed research question and proposed specific aims (no more than 4) for the external fellowship bid.
Question:
Specific Aims:
c. Please indicate (i) your proposed start date of this pump-priming (ii) the external deadlines for which you will make applications.

Exploitation (If applicable, summarise in up to a maximum of 100 words any potential for commercial exploitation/application)

Itemise and estimate the consumable / running costs for the year with justification; max £5,000

NHS service support costs (if these are relevant to your research, please detail how they will be covered)

Has this application and desire to compete for subsequent external fellowships been discussed with and gained approval from your specialty Training Programme Director and, if exists, Academic Programme Lead? Please list names.

Part C: The Supervisor(s)

Supervisor / Co-supervisor
Name
University Position
Clinical position (if appropriate)

Please list other co-applicants, providing details as above:

Co-applicant / Co-applicant / Co-applicant / Co-applicant / Co-applicant
Name
University Position
Clinical position (if appropriate)

Statement on the applicant’s scientific ability and suitability for pump-primingtowards a nationally awarded doctoral fellowship (max 300 words)

PhD / MD / MPhil

Number of students supervised previously

Number of students currently supervised

Number, name and grade (i.e. MRC clinical training fellow; NIHR clinician-scientist) of fellows sponsored / supervised in the past who have held nationally awarded fellowships from MRC, Wellcome Trust, NIHR (not ACF / ACL) or AMRC members.

Current Grants held as principal investigator

C5 Supervisor Publications

Using a maximum of 1 side of A4 please provide full details of recent and relevant prior publications to support this application. Please indicate with * publications relevant to the project
Please add as a separate sheet.

Signature of Principal Supervisor:______

Please email completed form to

by Monday 30th October 2017 (9AM)