Vanguard Grants Application Form 2013

Vanguard Grants Application Form 2013

Vanguard Grant

Application Form

  1. Project Title

Simplified Project Title: / (100 characters max) / Research Category:
Scientific Project Title: / (300 characters max) / Click here ClinicalPublic HealthHealth Services
  1. Applicant Details

Title: / Click hereMsMrsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline: / Mobile:
Gender / Click here MaleFemalePrefer not to say
Email:
Position: / Institution type:
Position Start Date: / mm/yyyy / Current Salary ($) / FTE: / Click here1.0 FTE0.9 FTE0.8 FTE0.7 FTE0.6 FTE0.5 FTE0.4 FTE0.3 FTE0.2 FTE0.1 FTE
I am an Australian or New Zealand Citizen (attach a birth certificate or passport to Q15).
I am an Australian Permanent Resident (attached permanent resident certificate or evidence of submission for Australian Permanent Residency to Q15).
Click here NeitherAboriginalTorres Strait IslanderBothPrefer not to say / Are you of Aboriginal or Torres Strait Islander descent?
  1. Administering Institution Details
Please ask permission before including other people’s personal information. The Privacy Statement at the end of this document should also be noted
Institution Name: / Address:
ABN: / Suburb: / State: / Postcode:
Research Office:
RAO Contact Person: / Title: / Click hereMsMrsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline: / Email:
Mobile:

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  1. Ethics Type

Is Ethics Required? Please select Ethic requirements associated with your research.
Select all Ethic requirements associated with your research:
No Ethics Required
Human Ethics
Other (please specify) (200 characters maximum)
  1. Project Start Date

Project Start Dtae: / Click here 1st January 20181st April 20181st July 2018
  1. Project Synopsis /Potential Outcomes

Using lay terms, describe the overall aims of the research and expected cardiovascular health outcomes. Avoid technical terms. Your answer should be suitable for release to media and general publications.
(1500 characters maximum)

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  1. Other Chief Investigators
Please ask permission before including other people’s personal information. The Privacy Statement at the end of this document should also be noted
A maximum of three other chief investigators may be included in the application:
Title: / Click here MsMrsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline (include area code): / Mobile:
Email: / Gender / Click here MaleFemalePrefer not to say
Are you of Aboriginal or Torres Strait Islander descent? / Click here NeitherAboriginalTorres Strait IslanderBothPrefer not to say
Position: / Current Institution:
Role in project: / (500 characters max)
Title: / Click here MsMrsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline(include area code): / Mobile:
Email: / Gender / Click here MaleFemalePrefer not to say
Are you of Aboriginal or Torres Strait Islander descent? / Click here NeitherAboriginalTorres Strait IslanderBothPrefer not to say
Position: / Current Institution:
Role in project: / (500 characters max)
Title: / Click here MsMrsMrDrAssoc. ProfProfAss. ProfEm. Prof / First Name: / Last Name:
Landline(include area code): / Mobile:
Email: / Gender / Click here MaleFemalePrefer not to say
Are you of Aboriginal or Torres Strait Islander descent? / Click here NeitherAboriginalTorres Strait IslanderBothPrefer not to say
Position: / Current Institution:
Role in project: / (500 characters max)

EXECUTIVE SUMMARY

  1. Relevance to the Purpose of the Award
How does the proposed project test the feasibility of an innovative concept in public health, health services or clinical service delivery?
(2000 characters maximum)
  1. Expected Outcomes
What outcomes are expected from the project and how might these outcomes lead to improvements in cardiovascular health?Will this study lead to larger, more rigorous studies in the future? If so, how is it proposed to fund these studies?
(2000 characters maximum)

Research Proposal

  1. Project Plan

Please provide a brief summary of your project plan.
(1500 characters maximum)
  1. Research Environment

Briefly summarise the research environment including quality/experience of supervision, international standing of lab, facilities, infrastructure and funding that is available to support your proposed research.
(1000 characters maximum)
  1. Research Plan and Figures

Research plans are limited to three pages (including all tables, all figures, and no more than 15 references) and must be completed using Arial 12 point font with single line spacing. Do not alter page layouts, borders, page or section breaks or any other formatting.Plans must start under this header. All documents not adhering to these guidelines will be reformatted and any additional information exceeding three pages will be automatically deleted. Documents significantly deviating from these guidelines will not be considered further.

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  1. Track Record of the Applicant

Please provide a brief summary of your track record (including publication, presentations, grants and awards) focussing on aspects of your track record, training and skills relevant to the proposed project.
(4000 characters maximum)
  1. Project Budget

Briefly indicate (in round dollars) how project funding provided by the Heart Foundationwill be spent.
Budget Type / Details
(200 characters maximum) / Year 1 / Year 2 / Year 3 / Year 4
Click here PersonnelEquipmentMaintenanceOther
Click here PersonnelEquipmentMaintenanceOther
Click here PersonnelEquipmentMaintenanceOther
Click here PersonnelEquipmentMaintenanceOther
Click here PersonnelEquipmentMaintenanceOther
Sub Totals
Budget Total

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Evidence of Citizenship

  1. Evidence of Citizenship

Insert evidence of citizenship, Permanent Residencyor application for Permanent Residencybelow. Two pages maximum including this page.

Insert here

Signatures

Applicant
I certify that all details provided in the application (including annexures) are correct and that I have read, understood, and have abided by the instructions associated with this form.
I agree to carry out the project in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007). I acknowledge that all ethics approvals and clearances necessary to complete my project as outlined in this application must be in place before commencement of the work and that the Heart Foundation will not release funds until such time as a copy of all such approvals and clearances have been received by the Heart Foundation Research program.
By signing, I confirm that I have complied with all instructions in the application form and understand that failure to do so may result in the withdrawal of the application from the review process.
I also acknowledge all supporting documentation has been provided with this application. I understand that my application will not be eligible for consideration by the Heart Foundation if this application is incomplete or lacking the required documents.
Please see our Privacy Statement at the end of this document
Title: / First Name: / Last Name: / Date
Signature: / __/__/2017
Head of Department
I certify that appropriate facilities will be available to the applicant if successful and that I am prepared to have the project carried out in accordance with the Australian code for the Responsible Conduct of Research (2007).
Please see our Privacy Statement at the end of this document
Title: / First Name: / Last Name:
Email: / Landline:
Department: / Date:
Signature: / __/__/2017
Verification by Research Office
I, a representative of the Institution’s Research Office, verify that I have checked this application and that to the best of my knowledge, all instructions included in this form have been complied with and all relevant details are correct at the time of lodgement with the Heart Foundation.I acknowledge that the Heart Foundation will not release funds until such time as a copy of necessary ethics approvals and clearances have been received by the Heart Foundation Research program.In addition, I verify that this institution has established administrative procedures for assuring sound scientific practice in accordance with the principles of the Australian Code for the Responsible Conduct of Research (2007).
Please see our Privacy Statement at the end of this document
Title: / First Name: / Last Name:
Email: / Landline:
Position:
Institution Name: / Date:
Signature: / __/__/2017

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Privacy Statement

Your Personal Information is being collected by the Heart Foundation in order to assess your application for this grant. If you are not successful in your application we will retain your application on file indefinitely . We respect your privacy and embrace the principles contained in the Privacy Act. The Heart Foundation (we, us, our) is the National Heart Foundation of Australia and all associated Australian State and Territory Heart Foundation Divisions, full details of which can be found in our Privacy Notice.

If you do not want to receive further communication from us (other than information that relates to this application) or if you have any questions about privacy please contact the Research Program at or call (03) 9321 1581. Our APP privacy policy is set out in our Privacy Notice and details how you may complain about privacy issues and how we would deal with that complaint. It also explains how you can access, correct or update information we hold about you. A copy of our Privacy Notice is available at or on request. [HFPS06-140410-F]

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