Healthwatch Research Fund Grant Proposal and Application Form

HealthWatch Research Fund – Grant proposal and application form

Before completing this form you should read the document HealthWatch – charitable aims and research, which is appended at the end of this application form

All sections of this application form must be completed, and the completed form must be submitted as an email attachment sent to the Secretary, Prof David A Bender ().

Principal applicant

Title and name:

Present position or occupation:

Contact address:

Telephone (including area codes):

Email:

Title of project (maximum 50 words)

Aims and objectives of the project (maximum 500 words)

How does this project map onto the aims and objectives of HealthWatch? (maximum 250 words)

Proposed duration of the project

Description of the proposed project; methodology and milestones (maximum 1000 words)

Is ethical approval required for this project? If so, which ethical committee will be asked for approval?

How will you disseminate the results of your project?

How much funding are you requesting?

Do you have any other funding for this project? If so, please give details

Justification for the funding requested (maximum 500 words)
Brief curriculum vitae of the principal applicant to indicate his/her suitability to carry out the proposed project.

If appropriate, please include references for up to 5 research publications in peer-reviewed journals or other relevant publications.

Please list any research or other funding you have received over the last 5 years, showing the funding agency or body, the duration of the grant and the amount received.

Do you consider that you have any (potential) conflicts of interest or competing interests (financial or otherwise)? If so, please describe them; if not please state that you have no conflicts of interest or competing interests.

Co-applicant(s) (This page should be repeated if there is more than one co-applicant)

Title and name

Present position or occupation

Contact address

Telephone (including area codes)

Brief curriculum vitae (including any recent research publications)

This page must be signed by the principal applicant and all co-applicants, and where appropriate also by the principal applicant’s head of department or line manager agreeing that departmental facilities may be used for the proposed research. It may be scanned and appended to the application form when it is submitted by email, or scanned signatures may be inserted into the document. Failing this, the signed copy of this page should be sent separately to Prof David Bender at 8 Eagle Close, Amersham, Bucks HP6 6TD.

Title of project

Principal applicant (title and name)

I / we agree:

· to carry out the proposed project to the best of our ability;

· to submit progress reports as required in a timely fashion;

· to submit a final report within 3 months of the completion of the project;

· to maintain proper accounting for the funds provided, including receipts for all purchases and other expenditure;

· that HealthWatch will have the right to publish reports of the outcomes of all funded projects on its website and in its Newsletter.

I / we confirm that:

· Ethical approval has been or will be sought if appropriate;

· All potential conflicts of interest or competing interests have been declared.

Signed (principal applicant)

Date

Co-applicants (to be repeated for each co-applicant):

Name

Date

signature

Where the principal applicant is employed, the Head of Department, line manager or other appropriate representative of the employer must sign below to agree that the principal applicant has permission to use the employer’s facilities to conduct the research described in this application.

I agree that the proposed research has my approval and the applicant may conduct the research using the facilities of my company / institution / department.

Name

Position and Company / institution

Date

Signature