WCH FOUNDATION

Population Health

Medical Postgraduate Scholarship

RESEARCH COMMENCING IN 2018

Application Form

  1. Personal Details:

NAME:
Title/ First / Surname
Date of Birth: / Place & Country of Birth:
Australian citizenship and residential status:
  1. Contact Details

Postal/Delivery Address:
Department /Division (of WCHN):
(Floor/Level/Building)
Telephone (work): / Mobile:
Email:
  1. Proposed course and institution

Proposed Course to be undertaken:
(Masters by Research or PhD)
Proposed Institution of enrolment:
University of Adelaide / University of South Australia / Flinders University
Proposed date of commencement/completion:
  1. Eligibility

Certified copies of academic records / transcripts of each tertiary institution attended are required. (Please attach with signed original application). ATTACHED: YES / NO
  1. Curriculum Vitae

Please include a CV as a separate document outlining the points listed below (Maximum 3 pages):
5.1Education(include academic and professional qualifications, date conferred, Institution conferring)
5.2Employment history(include present position/appointment at WCHN am length of service)
5.3Awards and Fellowships received
5.4Previous Research Experience(including completed research projects, research grant achievement and brief summary of research projects)
5.5Research publications
5.6Research presentations
ATTACHED: YES / NO
  1. Outline of research project

6.1Name of Department(s): (in which the research work will be undertaken)
6.2Title of the research project:
6.3Abstract of the research project:in lay terms (200 words or less)
6.4Brief description of the research project: (3 pages or less), including research objectives, the significance for paediatric, child or maternal health, research methods, data analysis and interpretation techniques
6.5Any special facilities required, particularly in regard to equipment and space?
6.6Describe how obtaining a Masters by Research or PhD would enhance your research career and benefit WCHN:
6.7Describe how you intend to pass on the information gained to your colleagues at WCHN and others:
6.8Detail the costs you wish covered by the Population Health Medical Post-Graduate Scholarship and state also those costs which will/may be met from other sources e.g. departmental support.
6.9A letter from the Head of the Department concerned, supporting the application, and confirming that the Department can provide appropriate facilities and supervision for the proposed research, should the application be successful. (please attach)
ATTACHED: YES / NO
  1. Other information

The applicant should provide any other information which may help in the assessment of the application.
  1. Referee reports

The applicantmust request a written report from two(2) referees.This report should include the referee’s name, address, and contact details and outline the applicant’s academic abilities and personal suitability to undertake the proposed research, and who may be prepared to evaluate the project proposal.
Referee reports should be sent directly to Research Grants Officer, C/- WCHN Research Secretariat or via email to the closing date. Please note that it is the scholarship applicant’s responsibility to ensure that referee reports are received by WCHN Research Secretariat, by the due date for applications.
Please provide the names and contact details for each of your nominated referees below:
Referee 1
NAME:
Title/ First / Surname
Department /Division: / Telephone:
Email:
Referee 2
NAME:
Title/ First / Surname
Department /Division: / Telephone:
Email:
  1. Proposed Supervisors

It is expected that in preparing this application the applicant will have contacted the relevant South Australian University (Adelaide, UniSA or Flinders) and have discussed this application and possible supervisors with the Postgraduate/Higher Degrees Co-ordinator. It is expected that the University will have nominated a qualified supervisor who will be willing to supervise the student if their application is successful. The Lead Supervisor should be a staff member of the Women’s and Children’s Health Network (WCHN).
Name of proposed supervisor:
NAME:
Title/ First / Surname
Postal/Delivery Address:
(Floor / Level / Building)
Department /Division:
Telephone (work): / Mobile:
Email:
Academic Qualifications:
Signature of Proposed Supervisor: / Date:
Name of proposed supervisor:
NAME:
Title/ First / Surname
Postal/Delivery Address:
(Floor / Level / Building)
Department /Division:
Telephone (work): / Mobile:
Email:
Academic Qualifications:
Signature of Proposed Supervisor: / Date:
Name of Higher Degree/Postgraduate Coordinator:
NAME:
Title/ First / Surname
Telephone (work):
Email:
Signature of Proposed Higher Degree/
Postgraduate Coordinator: / Date:
  1. ETHICAL/SAFETY and Governance CLEARANCES

This section MUST be completed.To verify what clearances are required refer to:

Approval required / Approval attached / Approval number(s)
Human Research Ethics / Yes / No / Ethics:
Governance:
Is the title of you proposed project the same as the approve ethics
Yes No
Yes
No / If NO approval, has application been submitted: Yes No
If NO, when will you submit: /
Animal Ethics / Yes / No / Ethics:
Is the title of you proposed project the same as the approve ethics
Yes No
Yes
No / If NO approval, has application been submitted: Yes No
If NO, when will you submit: /
Institutional Biosafety / Yes / No / Ethics:
Is the title of you proposed project the same as the approve ethics
Yes No
Yes
No / If NO approval, has application been submitted: Yes No
If NO, when will you submit: /
If you have indicated above that ethics approval is not required, please provide justification below that your study does not involve any animals, patients, patients’ families, patient tissue (including stored tissue), patient information and/or staff. It is recommended you discuss your project with the Chair of the WCHN relevant Ethics Committee (HREC / AEC / IBC) to clarify this matter and provide written confirmation from the relevant Chair.

Please note if successful:

The applicant must provide notification of ethics and governance approval to the Research Grants Officer by 31 March.

If this application has a different title from that which is on the ethical/safety clearance, you MUST provide a statement to the relevant committee requesting the new title be added and state if there are any changes to the protocol (ie an amendment to the protocol).

On receipt of the HREC letter indicating the addition of a title has been approved– please forward a copy of the letter to the Research Grants Officer.

Approval for your project and processing payment of the awardwill not been granted until written confirmation is received from the relevant ethics/safety committee and/or Research Governance Officer.

  1. Certification

Signatures date and endorsement
All applications are to be signed, dated and endorsed, as outlined below, by the applicant, Department Head, Divisional Director and Executive Director.
Applicant
Signature: ______Date: ______
Endorsement of Application
Department Head
Acknowledging consent and support for the application, and budget provision for backfill (if required) during the Scholarship (attach include letter from Department Head) – see 6.9
Name: ______
Signature: ______Date: ______
Divisional Director
Name: ______
Signature: ______Date: ______
Executive Director
Name: ______
Signature: ______Date: ______
  1. Submitting Application

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12
12.1The applicant is required to submitthe original signed hard copy of the application plus five(5)photocopies of the application, sent/delivered to: Ms Katherine McPhail, Research Grants Officer, C/- Research Secretariat, Level 2, Samuel Way Building, Women’s and Children’s Health Network, 72 King William Road, NORTH ADELAIDE SA 5006
12.2The applicant must also submit an electronic copy of the application (in Word Format) via email to: (signature not required on this version).
NB: Late and/or unsigned applications WILL NOT be accepted.

Applications Close: 4.00pm Monday 16 October 2017

On behalf of:

WCH Foundation Inc.

WCH Foundation grants application form – 2017 Page 1 of 6