Cochrane Fellowship Application Form 2016

Cochrane Fellowships Application Form 2016

Please complete in typescript and return by24 May 2016 at 1pm.

1. Applicants Details
Name:
2. Current Work Details
Title/Position:
Department:
Address:
Tel Number:
Fax Number:
Email Address:
3. Home Address
Address:
Tel Number:
Fax Number:
Email Address:
4. Details of institution where review will be carried out and the Head of Department
Name:
Position/Title:
Address:
Tel Number:
Fax Number:
Email Address:
5. Summary of the Review (limit 1000 words)
Review Title:
6. Please give details of any preliminary or previous work carried out relevant to this application (600 words)
7. Name of Cochrane Review Group (CRG)
Name:
7b. Please select the type of review you plan to undertake
Please tick /
  • Cochrane healthcare intervention review

  • Cochrane methodology review

8. Has the Cochrane Review Group’s approval been obtained

Yes Please note: An electronic copy of the approval letter must be included with the application
Please give details of the CRG Co-ordinatorwho issued the approval letter
Name:
Position:
Tel Number:
Fax Number:
Email Address:
9. Details of Local Supervisor who has agreed to support the Fellow
Name:
Position:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
If the local supervisor is not based within the employing institution, please describe the arrangements envisaged for ongoing supervision over the term of the review.
What experience in conducting systematic reviews does your local supervisor have?
10. Details of contact editor nominated by the Cochrane Review Group, if applicable
Name:
Position:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
11. Details of other co-reviewers, if applicable
Name:
Department:
Institution:
What experience in conducting systematic reviews does the co-reviewer have?
12. Proposed Benefits (Max 400 words)
13a. Please indicate how much time you intend to spend conducting the systematic review
Days/ Week:
Inclusive Dates
Start Date:
End Date:
Please indicate how you intend to spend your non-Fellowship time and manage the separation of your Fellowship and your work time
13b.Please provide a brief dissemination and Knowledge Transfer Plan for sharing the findings of the review with key stakeholders
(limit 600 words)
14. Please detail any plan to involve patients and public in the development, design and dissemination of the review, where relevant (Limit 500 words)
15. Finance
Current Grade:
Salary / Year 1 / Year 2 (if applicable)
Full Time / Pro-rata / Full Time / Pro-rata
Current Basic Grade Salary
Employers costs
(E.g. superannuation, national insurance PRSI)
Total:
Training and Travel
(e.g. Attendance at Relevant Courses / Travel to collaboration meetings) / Year 1 / Year 2 (if applicable)
Total:
(Max £2, 000 over duration of award)
c / Research Expenses(Photocopying, translation costs, Dissemination) / Year 1 / Year 2 (if applicable)
Total:(Max £1,500 over
duration of award)
Overall total:
*For each of the items listed above please provide justification
16. Please give details of 2 referees who may be contacted to establish your suitability for this Fellowship
Referee 1
Position:
Department:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
Referee 2
Position:
Department:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
17. Declarations
Name of Applicant:
Applicant / “I have read ‘Guidance for Applications for Cochrane Fellowships’ and agree to abide by the conditions under which a Cochrane Fellowship is awarded. I declare that all the information provided in this application form is correct”.
Print:______
Signature:______
Date:______
Local Supervisor / “I approve this application and am willing to supervise/ mentor the Fellow as required”
Print:______
Signature:______
Date:______
“I have read this application and am willing to support the conduct of this review in my institution, if successful”. / Head of Department / Current Employer
(If Different)
Name:
Position:
Institution:
Address:
Tel Number:
Fax Number:
Email Address:
Print
Signature
Date

Please note that a hard copy of the declarations page of the application form, with original signatures, must be submitted to HSC R&D Division by24 May 2016at 1pm.

1 The HSC Research & Development Division of the Public Health Agency

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