Nursing and Midwifery
Research Fellowships
Application Form
2014
Applications close 5:00 pm AEST 30 January 2015
Applicant’s name:
Nursing and Midwifery Research Fellowships Application Form
Published by the State of Queensland (Queensland Health), December 2014
This document is licensed under a Creative Commons Attribution 3.0 Australia licence.
To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au
© State of Queensland (Queensland Health) 2014
You are free to copy, communicate and adapt the work, as long as you attribute the
State of Queensland (Queensland Health).
For more information contact:
Health and Medical Research, the Department of Health, GPO Box 48, Brisbane QLD
4001, email hmr@health.qld.gov.au, phone +61 (0) 7 3328 9503.
An electronic version of this document is available at
http://www.health.qld.gov.au/ohmr/html/rpu/proj_grants.asp
Disclaimer:
The content presented in this publication is distributed by the Queensland Government as an information source only.
The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or
reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all
liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might
incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed
on such information.
1.
Application instructions
Before completing this form, please ensure that you have read all relevant
documentation outlined below.
Health and Medical Research (HMR), Preventive Health Unit, the Department of Health
will call for applications from 8 December 2014. This application will be assessed by an
expert review panel against the selection criteria at Section 7. The panel is comprised
of expert representatives from nursing and midwifery backgrounds.
1.1
Submission of application
Nursing and Midwifery Research Fellowship submission
Step
It is recommended that applicants:
One
Read the Nursing and Midwifery Research Fellowships Funding Rules
www.health.qld.gov.au/ohmr/documents/nurse_fundrules.pdf
Two
Read Nursing and Midwifery Research Fellowships Legal
Requirements 2014
www.health.qld.gov.au/ohmr/documents/nurse_legal.pdf
Three
Complete this application form (Nursing and Midwifery Research
Fellowships Application Form)
www.health.qld.gov.au/ohmr/documents/nurse_appl.doc
Four
Submit application to hmr@health.qld.gov.au
1.1.1 Application form
All applications must be submitted using this form (as per format at Section1.1.3)
1.1.2 Closing date
Applications are to be submitted to the HMR@health.qld.gov.au email account by 5pm
AEST 30 January 2015. Late applications will not be accepted.
If applicants have difficulty submitting applications, please contact the Department of
Health on telephone +61 7 3328 9503 to make alternative arrangements.
1.1.3 Format of lodgement
The application will be submitted in a single Adobe Acrobat Portable Document Format
(.pdf). Please ensure that the software used is compatible with version 11 of Adobe
Acrobat.
Applicants will submit their application on this form using:
Nursing and Midwifery Research Fellowships Application Form
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
Arial 10.5 point

Single-spaced font

2 cm page margins.
The application form must be submitted in its original form. Applicants are not permitted
to edit the underlying template of the application form.
1.1.4 Naming the file
The following naming convention should be used in the document file name (do not
include spaces) – the surname and first name refers to the Chief Investigator (CI):
HMR_NurseMid_SURNAME_FIRSTNAME.PDF
1.1.5 Certification
Applicants have the option of submitting the final signed certification page as part of
their application (preferred), or as a second separate attachment with the file name –
the surname and first name refers to the CI:
Cert_HMR_NurseMid_SURNAME_FIRSTNAME.PDF
2.
Nursing and Midwifery Research Fellowship
categories
Please indicate below the category of Nursing and Midwifery Research Fellowship that
you are applying for. Please note that as a CI, you are only eligible to apply for one of
the following four research fellowships.
Novice Research Fellowship (2 research fellowships are available at a
maximum of $10,000 per research fellowship over 12 months)
Early-Career Research Fellowship (2 research fellowships are available at a
maximum of $15,000 per research fellowship over 12 months)
Experienced Researcher Fellowship (1 research fellowship is available at a
maximum of $60,000 per annum for 2 years: a total of $120,000 per research
fellowship)
Research Implementation Fellowship (2 research fellowships are available at a
maximum of $60,000 per annum for 2 years: a total of $120,000 per research
fellowship)
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3.
Personal details of Chief Investigator
Personal details of Chief Investigator
Family name
Given name(s)
Title
(Prof, Dr, Mr, Mrs, Ms etc)
Gender
Male/Female
Postal address
Suburb/town
State
Postcode
Country
Courier address (Line 1)
Courier address (Line 2)
Suburb/town
State
Postcode
Country
Work phone number
Facsimile number
Mobile phone number
Email address (contact is
via email in the first
instance)
Secondary mail address
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Citizenship/resident details of Chief Investigator
Citizenship
Primary place of residence
If not an Australian citizen,
please indicate if you are a
permanent or temporary
resident, or hold a Special
Category Visa (please
provide certification copies
of relevant documentation).
If not a holder of the above,
has a residency permit or a
Special Category Visa
been sought? Please
provide details.
Equal employment/diversity information – please indicate if you (the Chief
Investigator) identify with any of the following groups. The completion of this section is
voluntary.
People with a disability
Yes/No
People from a non-English
speaking background
Yes/No
Aboriginal
Yes/No
Torres Strait Islander
Yes/No
Australian South Sea
Islander
Yes/No
4.
Qualifications of Chief Investigator
Academic/research qualifications – Copy and paste the table below as many time
as required
Academic qualification (e.g.
BNurs, MSN, PhD)
Institution
Year
Topic/Majors
Clinical qualifications – Copy and paste the table below as many times as
required
Professional Qualification
(e.g. certificate, FACN)
Institution
Year
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Clinical registrations – Copy and paste the table below as many times as
required
Clinical registration type
(e.g. general)
Professional body and
jurisdiction
Registration number
Status (eg current)
5.
Current appointments of Chief Investigator
Copy and paste the table below as many times as required for each separate
appointment. Please include any relevant clinical, research or academic appointments.
Current appointments and research appointment/s
Job title (e.g. Clinical
Nurse, Research Fellow)
Organisation (e.g. Metro
North Hospital and Health
Service)
Location (e.g. Royal
Brisbane and Women’s
Hospital)
Current status of position
(eg permanent full
time/temporary full
time/part time/contract)
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6.
Proposed area of research
To assist in providing appropriate peer review for your application and for statistical and
reporting purposes, please provide the most appropriate descriptors from the lists
provided by the National Health and Medical Research Council
(http://www.nhmrc.gov.au/grants/policy/keywords.htm).
Area of research
Broad research area
Select only 1 area
Field of research
Select only 1 field
Research
keywords/phrases
Select at least 3 but no more than 5 research
keywords/phrases
Socio-economic objective
Select at least 1 but no more than 5 objectives
Plain English summary
Provide up to five sentences that best encapsulate the
research in lay terms (this may be used by the
Department of Health in promotions and/or media
releases).
Does your application address one of the National Health Priority Areas (NHPAs)? (see
section 5, Funding Rules). If yes please specify which NHPA your application
addresses.
Selection criteria 1 – Research quality
7.

40% for all four categories of research fellowships
In your answers, please ensure you address the selection criteria in Section 7 of the
Nursing and Midwifery Research Fellowships Funding Rules.
7.1
Research plan
Location of research
In this section, include where the research will be undertaken, e.g. university or hospital
(maximum 50 words)
Title of research project (maximum 100 words)
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Brief background/literature review
In this section, include the current knowledge in your proposed field of research and
highlight any gaps in the knowledge (maximum one page)
Aims and rationale of research (maximum five sentences)
Research hypothesis (maximum five sentences)
Brief methodology
In this section, include relevant technologies, statistical and analytical methods
(maximum one page)
Assistant investigator/s
In this section include all key team members/assistant investigator/s. Copy and paste
the table below as many times as required.
Name
Job title
Place of employment
Role in project team
Percentage contribution of
team member
Briefly describe the benefit
of the collaboration
Expected outcomes
What outcomes are sought from the project and how will they be measured?
(maximum one page)
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In the section below, describe the proposed milestones for the research fellowship.
Ensure the milestones are focused to achieve the desired outcomes.
If the application is successful, the completion of milestones will be addressed in the
progress reports.
Do not include:

Writing grant applications

Applying for and obtaining ethics approvals and governance authorisation –
this is mandatory prior to beginning any research project

Recruitment of staff

Attendance at conferences or symposia.
Milestones
Briefly outline the proposed milestones for the project and the dates by which they are
expected to be completed. Insert as many additional rows as necessary.
Milestone 1
Insert date by which milestone is
expected to be completed
Milestone 2
Insert date by which milestone is
expected to be completed
8.

Selection criteria 2 – Significance and/or
innovation
25% for experienced researchers and research implementation applicants; 40% for
novice researcher and early-career researcher applicants
Describe the originality of the research and the potential importance or impact of the
project on the field (maximum one page).
Describe the project vision for Queensland (maximum one page)
This may include (but is not limited to) the means by which the funding of the project
will:
 address areas of need regarding the health of Queenslanders
 lead to improved patient outcomes, through innovation or the implementation or
change to guidelines or policies (ie translation into practice)
 facilitate new dimensions of leadership, training, team building, collaboration
and leverage of external funds
 integrate with your research and contribute to improved research culture and
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clinical practice in Queensland’s publicly funded health care facilities.
Selection criteria 3 – Track record of Chief
Investigator
9.

25% for experienced researchers and research implementation applicants; 10% for
novice researcher and early-career researcher applicants)
Researchers applying as a novice nurse/midwife researcher will not be assessed on
their track record, rather their ability to undertake research, including a good support
network, sound project idea and methodology, and good understanding of the research
area.
Evaluation of this selection criterion is also based on the track record of the identified
mentor and their ability to support a novice researcher. As a novice researcher, please
ensure you provide any relevant details regarding your track record first,then provide
details of your mentor’s track record.
9.1
Publications
In the section below, list your most significant publications from the last five years,
which are relevant to this research application.
Please describe, in one or two sentences, the significance of your top five
publications.
Publications could include:

peer-reviewed research papers

patents applied for or granted

reviews, letters, notes

books or book chapters

technical or other reports, including non-peer reviewed technical reports that
have had an impact on policy, practice or commercialisation

inquiries, other journal contributions

conference abstracts/proceedings.
List your most significant publications relevant to this research application (maximum
two pages)
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9.2
Key conferences and meetings participation
In the section below, list your most significant participation in key conferences and
meetings, which are relevant to this research application.
Participation may include (but is not limited to):

Keynote addresses

Presentations

Involvement on relevant committees.
Participation in key conferences and meetings (maximum one page)
9.3
Major research grants
List any major research grants you have received in the last five years
(maximum one page)
9.4
Career disruptions
Outline any significant career disruptions lasting longer than six months that have
affected your ability to undertake hospital and health service/clinical duties or academic
research over the last five years. Examples include pregnancy and childbirth, major
illness, career responsibilities, parental leave, and industry or other work placements
where research was not able to be conducted. Applicants should nominate periods
where their career has been disrupted and provide a brief explanation of the reason.
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9.5
Leadership and training
In the section below, briefly outline your involvement in both research and
clinical/hospital and health service duties leadership and training. Dot points are
acceptable.
This may include (but is not limited to):

Involvement in leadership, training and mentorship

Involvement in supervision of clinical staff

Supervision of research staff (indicate level of students – honours, Masters,
PhD, postdoctoral)

Any courses or training that you have undertaken that has directly contributed
to your research work.
Research leadership and training (maximum half page)
9.6
Achievements, prizes and awards for research
and clinical/hospital and health service duties
Outline any significant prizes, honours or peer-recognition you have received for
research relevant to this application. Please include the name and brief details of the
award. Dot points are acceptable. (maximum one page)
9.7
Other professional activities and community
involvement
Outline any further significant professional activities and community involvement that is
relevant to this research proposal. Dot points are acceptable. (maximum half page)
10. Selection criteria 4 – Budget

10% for all four categories of research fellowships
Outline your budget for the proposed project, including justification (value for money)
for each line item (maximum one page).
Budget may include any direct research costs, including research assistants, contract
statisticians or other relevant experts, payment for services required such as pathology,
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administrative costs directly associated with the research project, travel, and
accommodation for data collection.
11. Identification of research mentor (for
applicants applying under the novice
researcher category only)
Applicants in the novice researcher category who do not have a research mentor will
not be considered.
Research mentor
Title
Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Research field
Academic qualifications
Clinical qualifications
Institute
Hospital/university etc
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact
Yes/No
12. Identification of novice researcher team
member for applicants applying under the
experienced researcher and research
implementation category
Novice researcher
Title
Prof, Dr, Mr, Mrs, Ms etc
First name, last name
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Clinical qualifications
Institute
Hospital/university etc
Office phone number
Mobile phone number
Email address
13. External assessors
The Department of Health reserves the right to appoint external assessors. These
external assessors may be provided with relevant documentation to complete the
assessment.
List a maximum of three name(s) below, of any people to be excluded from the external
assessment process where relevant (ie because of a significant conflict of interest).
Excluded external assessors (if relevant)
14. Referees
Applicants are required to contact and seek agreement from two referees to comment
on the Nursing and Midwifery Research Fellowship application. Please include the
contact details and the relationship of the referees to the CI (eg ‘current manager’). It is
preferred applicants provide referees that currently work closely with the applicant. If
possible, provide one clinical referee and one research referee.
Referee 1
Title
Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Postal address
Postal address
Suburb/town
State
Hospital/university etc
Postcode
Country
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Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact
Yes/No
Referee 2
Title
Prof, Dr, Mr, Mrs, Ms etc
First name, last name
Postal address
Postal address
Suburb/town
State
Hospital/university etc
Postcode
Country
Office phone number
Mobile phone number
Email address
Relationship to applicant
Permission to contact
Yes/No
15. Certification
Applicants have the option of submitting the final signed certification page as part of
their application (preferred), or as a second separate attachment using the following
naming convention for the file name
Cert_NurseMid_SURNAME_FIRSTNAME.PDF
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15.1 Chief Investigator certification
I, the applicant, certify that all details given in this application are correct
Applicant’s certification
Title
Prof, Dr, Mr, Mrs, Ms etc
Last name
Applicant's last name
First name(s)
Applicant's first name
Signature
Date
[DD/MM/YYYY]
15.2 Assistant investigator certification
Assistant investigator’s certification (copy and paste the table below as many times
as required)
Title
Assistant investigator's title
Last name
Assistant investigator's last name
First name(s)
Assistant investigator's first name
Signature
Date
[DD/MM/YYYY]
15.3 Research mentor certification (for applicants
applying for the novice researcher category only)
I, agree to act as a research mentor for [insert applicants name] should the applicant
be awarded a Nursing and Midwifery Research Fellowship in the novice researcher
category.
Research mentor certification
Title
Research mentor's details
Last name
Research mentor's details
First name(s)
Research mentor's details
Signature
Date
[DD/MM/YYYY]
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15.4 Novice researcher certification
This certification is to be completed by:

novice researchers on research implementation and experienced researcher
teams
and

by all assistant investigators on novice researcher teams.
I, [insert novice researcher's name] confirm that I am a novice researcher should the
applicant be awarded a Nursing and Midwifery Research Fellowship.
Novice researcher certification
Title
Novice researcher's details
Last name
Novice researcher's details
First name(s)
Novice researcher's details
Signature
Date
[DD/MM/YYYY]
15.5 Early-career researcher certification
This certification is to be completed by all assistant investigators on early career
researcher teams.
I, [insert early career researcher's name] confirm that I am an early-career researcher,
should the applicant be awarded a Nursing and Midwifery Research Fellowship.
Early career researcher certification
Title
Early-career researcher's details
Last name
Early-career researcher's details
First name(s)
Early-career researcher's details
Signature
Date
[DD/MM/YYYY]
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Department of Health
NurseMid – Applicaton form3 – 05.11.14
www.health.qld.gov.au
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