Metro South Health Report Cover Page Template

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CLOSING DATE: 5:00 pm MONDAY8 AUGUST 2016

All Research Support Grant applications are required to demonstrate cross disciplinary collaborations (e.g. across medical, allied health, nursing departments, and basic/clinical research) that strengthen collaborative research across Metro South Health (MSH) and upon the Princess Alexandra Hospital (PAH) campus. Research proposals must demonstrate potential for the research to be translated into improved health outcomes.

Small Grants ($25,000) are provided as seed funding for studies that will have the potential to build capacity. Funded by SERTA.

Project Grants($75,000) are provided as stand-alone support for defined projects with potential to result in future NHMRC (or similar) grants. Project Grants demonstrating Metro South Health (MSH) multi-site collaborations that strengthen collaborative research within MSH will be highly regarded. Funded by SERTA or PARF.

Large Project Grant($150,000) isprovided as stand-alone support for defined projects with potential to result in future NHMRC (or similar) grants. Applications demonstrating Metro South Health (MSH) multi-site collaborations that strengthen collaborative research within MSH will be highly regarded. Funded by SERTA.

Health Systems and Health Economics Project Grant ($75,000) specifically supports defined projects focusing on health systems and health economics.Funded by SERTA.

Application Instructions

Refer to the 2017 Funding Guidelines when preparing your application.

Press <Tab> to move between fields.

Failure to complete any sections will deem the application ineligible.

The Applicant is required to sign the application on behalf of the research team.

Submission

Applications must be submitted electronically to :

A signed copy of the application to be submitted as a PDF,
The application must also be submitted in Word format (signatures not required).

Files must not exceed 2 MB in size and should be named using the following naming convention:

Applicant Surname_2017 Funding Type

E.g., Smith_2017 Small

Applications must be received by the Centres for Health Research

no later than 5:00 pm Monday 8 August 2016

Late or incomplete applications will not be accepted

Enquiries

Enquiries regarding the PA Research Support Scheme should be directed to:

PAH Research Grant Administration Officer

Email:

PA Research Support Scheme

2017 Research Grant Application

Research Support Application Type

Small Grant / Health Systems and Health Economics
Project Grant / Large Project Grant

Project Title

(Maximum 200 characters including spaces)

Investigative team

The Applicant must be the PI (Principal Investigator).

The maximum number of: Co-Investigators (CIs) = 4; Associate Investigators (AIs) = 2

Title / Name / Health profession / Organisation
PI / Click to chooseProfA/ProfDrMrMrsMs / First nameSurname / Click to chooseMedicalAllied HealthNursingResearch OnlyOther / Click to chooseMSHUQQUTGriffith
CI1 / Click to chooseProfA/ProfDrMrMrsMs / First nameSurname / Click to chooseMedicalAllied HealthNursingResearch OnlyOther / Click to chooseMSHUQQUTGriffith
CI2 / Click to chooseProfA/ProfDrMrMrsMs / First nameSurname / Click to chooseMedicalAllied HealthNursingResearch OnlyOther / Click to chooseMSHUQQUTGriffith
CI3 / Click to chooseProfA/ProfDrMrMrsMs / First nameSurname / Click to chooseMedicalAllied HealthNursingResearch OnlyOther / Click to chooseMSHUQQUTGriffith
CI4 / Click to chooseProfA/ProfDrMrMrsMs / First nameSurname / Click to chooseMedicalAllied HealthNursingResearch OnlyOther / Click to chooseMSHUQQUTGriffith
AI1 / Click to chooseProfA/ProfDrMrMrsMs / First nameSurname / Click to chooseMedicalAllied HealthNursingResearch OnlyOther / Type name here
AI2 / Click to chooseProfA/ProfDrMrMrsMs / First nameSurname / Click to chooseMedicalAllied HealthNursingResearch OnlyOther / Type name here

Preferred Funding Body

Acknowledgement of SERTA grant payment conditions

(Only for Applicants seeking SERTA funding)

I, [First Name, Surname], acknowledge and accept that grant payments from SERTA:

Can only be made to a Metro South Health (MSH) employee.
Must be deposited into a MSH research cost centre.

Signature of Applicant: Date:

Applicant Eligibility Checklist

To be eligible for a 2017 Research Support Grant the Applicant must be able to answer:
Yes to questions 1-3
No to question 5 / Yes / No
1 / Are you a member of staff of:

MSH (or hold a formal appointment to MSH)?
A PAH academic partner university school or research institute based on the PAH campus (UQ SOM, UQDI, QUT IHBI)?
Griffith University and based at a MSH site?

2 / Will your appointment be at least 0.5 FTE for the duration of the grant?
3 / Is a MSH member of staff the PI or named as a CI on the application?
4 / Will the majority (more than 50%) of the research activity take place at the PAH campus?
5 / Is the proposed research activity currently funded through an award type currently listed on the Australian Competitive Grants Register or international equivalent?

Mandatory Questions

Applicant Appointment Fraction and Location

Provide the FTE for each of your MSH/academic partner university appointment(s) (e.g. 0.6) and indicate where you are based (this information will assist with determining the appropriate funding body should this application be successful)

MSH / UQ / QUT / Griffith University
FTE / FTE / FTE / FTE
PA Hospital
Beaudesert Hospital
Logan Hospital
QEII Jubilee Hospital
Redland Hospital
Community Centres
Maternity Services
Oral Health Service
Addiction and Mental Health / UQDI
SOM / IHBI
(at PAH) / PA Hospital
Beaudesert Hospital
Logan Hospital
QEII Jubilee Hospital
Redland Hospital
Community Centres
Maternity Services
Oral Health Services
Addiction and Mental Health

Applicant Appointment Details

Provide details of your MSH and/or academic partner university appointment(s) (maximum 300 characters including spaces)

E.g.: Occupational Therapist at PA Hospital; MSH provides UQ with 50% of my salary; QUT Postgraduate Candidate based at IHBI in the Translational Research Institute

NOTE: N/A (or similar) will not be accepted

Location of research activity

Provide details of where the majority (more than 50%) of the research activity will take place (maximum 300 characters including spaces)

If the majority of the research cannot be conducted on the PAH campus provide justification (maximum 300 characters including spaces)

For clinical research studies: If the MSH Governance Office has already approved the MSH site at which this study will be conducted, provide the site specific approval (SSA) number(s)

SSA / SSA//QPAH/ / SSA / SSA//QPAH/ / SSA / SSA//QPAH/

NOTE:

Full funding of a successful clinical research application is conditional upon site specific approval being provided by the MSH Governance Office
SSA approval letters must be sent to for the full award amount to be received

Eligibility Certification

I, [First Name, Surname], certify that I:

Meet the relevant eligibility criteria for the PA Research Support Scheme.
Have answered all mandatory questions.

Signature of Applicant: Date:

Principal Investigator (applicant)

Contact Details

Applicant name / Click to chooseProfA/ProfDrMrMrsMsFirst NameSurname
Position
Organisational department / Department name
Phone number(s) / Primary: / Secondary:
Email address
Postal address / Address line 1
Address line 2
Address line 3
Suburb and Postcode

Academic Qualifications

Qualification / Awarding institution / Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR

Participation

Summarise your participation in the broad research plan proposed in this application (maximum 300 characters including spaces)

Research Time

Expected 2017 time allocation to: / This study (hr/wk): / Other studies (hr/wk):
Do you expect to have an extended period of absence during 2017? / Yes No
If Yes, provide expected dates / DD/MM/YEAR - DD/MM/YEAR
Reason
(300 characters including spaces)

Publications

List publications produced in the last 5 years with ALL authors provided

Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system

Grants

Provide details of research funding received in the last 5 years and indicate whether the funding relates to the proposed research of this application

Funding body and type / Start date
End date / Amount / Relevant to this application?
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No
[DD/MM/YYYY]
[DD/MM/YYYY] / $ / Yes
No

Co-Investigator 1

CI1 Contact Details

CI1 name / Click to chooseProfA/ProfDrMrMrsMsFirst NameSurname
Position
MSH site / Click to choosePA HospitalBeaudesert HospitalLogan HospitalQEII Jubilee HospitalRedland HospitalCommunity CentreMaternity ServicesOral Health ServicesAddiction and Mental Health Services
Organisational department / Department name
Phone number
Email address

CI1 Academic Qualifications

Qualification / Institution / Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR

CI1 Participation

Summarise the role of CI1 in the broad research plan proposed in this application (maximum 300 characters including spaces)

CI1 Research Time

Expected 2017 time allocation to: / This study (hr/wk): / Other studies (hr/wk):
Does CI1 expect to have an extended period of absence during 2017? / Yes No
If Yes, provide expected dates / DD/MM/YEAR - DD/MM/YEAR
Reason
(300 characters including spaces)

CI1 Publications

List publications produced in the last 5 years with ALL authors provided

Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system

Co-Investigator 2

ci2 Contact Details

CI2 name / Click to chooseProfA/ProfDrMrMrsMsFirst NameSurname
Position
MSH site / Click to choosePA HospitalBeaudesert HospitalLogan HospitalQEII Jubilee HospitalRedland HospitalCommunity CentreMaternity ServicesOral Health ServicesAddiction and Mental Health Services
Organisational department / Department name
Phone number
Email address

CI2 Academic Qualifications

Qualification / Institution / Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR

CI2 Participation

Summarise the role of CI2 in the broad research plan proposed in this application (maximum 300 characters including spaces)

CI2 Research Time

Expected 2017 time allocation to: / This study (hr/wk): / Other studies (hr/wk):
Does CI2 expect to have an extended period of absence during 2017? / Yes No
If Yes, provide expected dates / DD/MM/YEAR - DD/MM/YEAR
Reason
(300 characters including spaces)

CI2 Publications

List publications produced in the last 5 years with ALL authors provided

Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system

Co-Investigator 3

cI3 Contact Details

CI3 name / Click to chooseProfA/ProfDrMrMrsMsFirst NameSurname
Position
MSH site / Click to choosePA HospitalBeaudesert HospitalLogan HospitalQEII Jubilee HospitalRedland HospitalCommunity CentreMaternity ServicesOral Health ServicesAddiction and Mental Health Services
Organisational department / Department name
Phone number
Email address

CI3 Academic Qualifications

Qualification / Institution / Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR

CI3 Participation

Summarise the role of CI3 in the broad research plan proposed in this application (maximum 300 characters including spaces)

CI3 Research Time

Expected 2017 time allocation to: / This study (hr/wk): / Other studies (hr/wk):
Does CI3 expect to have an extended period of absence during 2017? / Yes No
If Yes, provide expected dates / DD/MM/YEAR - DD/MM/YEAR
Reason
(300 characters including spaces)

CI3 Publications

List publications produced in the last 5 years with ALL authors provided

Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system

Co-Investigator 4

CI4 Contact Details

CI4 name / Click to chooseProfA/ProfDrMrMrsMsFirst NameSurname
Position
MSH site / Click to choosePA HospitalBeaudesert HospitalLogan HospitalQEII Jubilee HospitalRedland HospitalCommunity CentreMaternity ServicesOral Health ServicesAddiction and Mental Health Services
Organisational department / Department name
Phone number
Email address

CI4 Academic Qualifications

Qualification / Institution / Date
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR
DD/MM/YEAR

CI4 Participation

Summarise the role of CI4 in the broad research plan proposed in this application (maximum 300 characters including spaces)

CI4 Research Time

Expected 2017 time allocation to: / This study (hr/wk): / Other studies (hr/wk):
Does CI4 expect to have an extended period of absence during 2017? / Yes No
If Yes, provide expected dates / DD/MM/YEAR - DD/MM/YEAR
Reason
(300 characters including spaces)

CI4 Publications

List publications produced in the last 5 years with ALL authors provided

Indicate publications relevant to this application with an asterisk (*)
Press <Enter> after each publication to maintain the numbering system

Associate Investigators

Associate Investigator 1

Outline the role of AI1 in the broad research plan proposed in this application and indicate why AI1 has been included within the research team (maximum 1,000 characters including spaces)

Associate Investigator 2

Outline the role of AI2 in the broad research plan proposed in this application and indicate why AI2 has been included within the research team (maximum 1,000 characters including spaces)

The proposed Research

Translational Aspect of the Research Proposal

What is the translational aspect of your project?

T0 – Identification of opportunities and approaches to a health problem (basic research)
T1 – Findings from basic research tested for clinical effect and/or applicability (Phase I and II clinical trials; observational studies)
T2 – Health application to evidence based practice guidelines (Phase III clinical trials; observational studies; evidence synthesis and guidelines development)
T3 – Practice guidelines to health practices (dissemination research; implementation research; diffusion research; Phase IV clinical trials)
T4 – Practice to population health (outcomes research; population monitoring of morbidity, mortality, benefits and risk studies)
Not applicable

Definitions taken from UC San Diego Clinical and Translational Research Institute

Key Words

Provide up to 6 keywords that best describe the field of research

Keyword 1Keyword 2Keyword 3

Keyword 4Keyword 5Keyword 6

Aims & Hypothesis

Provide the aims and hypothesis for this study (maximum 1,000 characters including spaces)

Research Significance

Describe the expected outcomes and benefits of the proposed study (maximum 750 characters including spaces)

Research Proposal

Provide your research proposal on the following pages. Include background, research plan and references (maximum 4 pages including references)

NOTE: The following must be used when preparing your Research Proposal:

Arial font with a minimum size of 11 point (including tables, table legends and figure legends)
Line spacing of 1.5 lines
Top and bottom page margins of 2.5 cm
Left and right page margins of 2 cm

DO NOT alter headers or footers

Page 1 of 20

Delete this text and insert Research Proposal here

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Budget

Item / Description / Amount
Personnel/Salaries / $
Maintenance
(consumable items to be purchased) / $
Equipment / $
Other
(NOTE: computers will not be funded) / $
Total / $
Budget justification / (maximum 1,000 characters including spaces)

Other Submitted Grant Applications

Provide details of grant applications related to this study submitted to other funding bodies in the current year

Funding body and type / Project title / Budget
$
$
$
$
$
$

Reviewer Nominations

Applicants must nominated three reviewers for this application
For nominations to be eligible the Applicant must be able to answer Yes to all questions / Yes / No
1 / Are all three nominated reviewers external to MSH and the university school(s)/research institute(s) of all named investigators?
2 / Is at least one nominated reviewer from interstate or overseas?
3 / Are all three nominated reviewers an acknowledged expert in the field of the proposed research (i.e. publication track record, PhD or equivalent research experience)?
4 / Are all three nominated reviewers completely independent of the investigative team (including AIs) and without conflict of interest? (See section 7.1 of the 2017 Funding Guidelines)
5 / Have all three nominated reviewers agreed to be available from mid-August to mid-October to assess your application?

Reviewer 1

Name / Click to chooseProfA/ProfDrMrMrsMsFirst NameSurname
Health profession / Click to chooseMedicalAllied HealthNursingResearch OnlyOther
Organisation/Institution / Organisation/Institution name
Department / Department name
Phone number: / Email:
Availability confirmed? / Yes No
Comments (300 characters)
Who contacted this reviewer?

Reviewer 2

Reviewer 3

Excluded Reviewers

If relevant, list details of up to two reviewers you would like excluded from assessing your application and provide justification for their exclusion

Excluded Reviewer 1

Excluded Reviewer 2

Human / Animal Experimentation

Refer to the National Health and Medical Research Council’s National Statement on Ethical Conduct in Human Research (2007 updated March 2014) and/or the Australian Code of Practice for the Care and Use of Animals for Scientific Purposes (8th edition 2013)

Human Ethics / Yes / No / N/A
Does the project involve research on human subjects?
Has ethical clearance been granted by a Human Research Ethics Committee?
IfYes, please provide the HREC clearance number:
IfNo,has a human ethics application been submitted?
Animal Ethics
Does the project involve research on animals?
Has ethical clearance been granted by an animal ethics committee?
IfYes, please provide the animal ethics approval number:
If No, has an animal ethics application been submitted?

NOTE:

Funding of a successful application is conditional upon ethical clearance of the proposed research
Ethical clearance letters must be sent to for funding to be received

Agreements and Certification of Support

CERTIFICATION BY THE Principal INVESTIGATOR

I, [First Name, Surname], certify that written agreement (such as an email) has been obtained from all investigators named in this Research Support application and that all details provided are correct.

I understand that should this application be successful, all named Co-Investigators on this application will be required to sign the Acceptance of Offer.