The Royal College of Radiologists

Application for the

KODAK RADIOLOGY FUND SCHOLARSHIP 2018

Details of Applicant

Surname
Other Names (in full)
Correspondence Address
Daytime Telephone Number / Facsimile Number / E-mail address
Current Post / Name of Training Scheme or Hospital
Please list any previous funding granted in the last five years
Relevant publications (list 5)

Details of Co-applicant (1)

Surname
Other Names (in full)
Correspondence Address
Daytime Telephone Number / Facsimile Number / E-mail address
Current Post / Name of Training Scheme or Hospital
Please list any previous funding granted in the last five years
Relevant publications (list 5)

Details of Co-applicant (2)

Surname
Other Names (in full)
Correspondence Address
Daytime Telephone Number / Facsimile Number / E-mail address
Current Post / Name of Training Scheme or Hospital
Please list any previous funding granted in the last five years
Relevant publications (list 5)

Details of Co-applicant (3)

Surname
Other Names (in full)
Correspondence Address
Daytime Telephone Number / Facsimile Number / E-mail address
Current Post / Name of Training Scheme or Hospital
Please list any previous funding granted in the last five years
Relevant publications (list 5)

Details of Co-applicant (4)

Surname
Other Names (in full)
Correspondence Address
Daytime Telephone Number / Facsimile Number / E-mail address
Current Post / Name of Training Scheme or Hospital
Please list any previous funding granted in the last five years
Relevant publications (list 5)

Details of Co-applicant (5)

Surname
Other Names (in full)
Correspondence Address
Daytime Telephone Number / Facsimile Number / E-mail address
Current Post / Name of Training Scheme or Hospital
Please list any previous funding granted in the last five years
Relevant publications (list 5)

Project Summary

Project Title

Summary (no more than 500 words)
Proposed Duration and Dates of Project
Where is Project to be Carried Out?
Likely Contribution of Project to Patient Outcomes
Has there been Patient and Public Involvement? (PPI is optional, but viewed favourably)
If yes, please answer parts a) and b) below
a)Who advised on the project? (Please name the PPI group)
b)Briefly explain how PPI contributed to the applicatione.g. by agreeing the topic is a priority for patients or suggesting a change in approach.
For information, support and resources for researchers on how to involve members of the public in research, please visit: and
Note that PPI review of anapplication can be requested through the RCR (please email: ) provided the request is made by Monday 11 June 2018.Please allow at least 2 weeks for this to be completed.
Details of Funding
Total Amount of Funding Requested
Detailed Justification of the Financial Support Requested
Details of Other Funding Requested or Obtained
Details of Project
Background
Methods and Techniques of Study
Supervision Arrangements
Experience of Supervising Research Team
Details of Timescale/Project Breakdown

Details of Referees

Both referees must beexternal consultant clinical radiologistswho are unconnected to the project and, are based at different institutions to each other and the applicant. Please note that referees will be asked to comment on the merits of the project rather than the character of the applicant.

First Referee’s Full Name
Hospital Address
Daytime Telephone Number / Facsimile Number / E-mail address
Second Referee’s Full Name
Hospital Address
Daytime Telephone Number / Facsimile Number / E-mail address
Applicant’s Declaration

I declare that the information given on this form and in its enclosures is complete and correct. If the Kodak Radiology Fund Scholarship is awarded to me, I will use the money for the stated purpose and abide by the conditions of the award. If I have any difficulty in completing the project according to the timetable, I will inform the Medical Director, Education and Training of the Faculty of Clinical Radiology. All research will be conducted to the highest ethical standards and subjected to the permission and scrutiny of the local medical ethics committee and the institution(s) where the research will be conducted.

I agree with this statement (check box)

Date:

Documentation to be enclosed with Application Form

Curriculum vitae

Letter(s) of support from the project supervisor(s) at the centre(s) at which the project is to be undertaken.

Please email completed form and electronic copies of all accompanying documentation to:

to arrive no later than 5pm on Monday 16 July 2018.