Research Grant Awards 2011
APPLICATION FORM
Please complete this form using a standard sized font (no smaller than 10 point)
1
Project title (not more than 25 words):
Project summary (not more than 150 words):
2
Dates:
Duration of project in months
Proposed start date
Proposed finish date
3
Chief Investigator:
Title and full name
Full address
Telephone no/ext
Organisation
Fax no
E-mail address
Department
Hours per week
Position
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18 May 2011
4
Applicant’s details:
Title and full name (Principal applicant)
Full address
Telephone no/ext
Fax no
Organisation
5
E-mail address
Department
Hours per week
Position
Co-applicants:
Title and full name (Co-applicant)
Full address
Telephone no/ext
Fax no
Organisation
E-mail address
Department
Hours per week
Position
Title and full name (Co-applicant)
Full address
Telephone no/ext
Fax no
Organisation
E-mail address
Department
Hours per week
Position
Title and full name (Co-applicant)
Full address
Telephone no/ext
Organisation
Fax no
E-mail address
Department
Hours per week
Position
2
18 May 2011
6
Regulatory authorisations/approvals etc:
Ethical approval: (please tick)
Attached
Not Required
Requested/To be Requested
Animals: (please tick)
Not required
7
Requested/To be Requested
Support:
This project has been submitted within the past year to:
This project is currently being submitted to:
Other research grants currently held (organisation, project title, funding and period of support):
Is there any overlap between this application and the other grants that you hold or are applying for?
(organisation, project title, funding and period of support):
8
Commercial exploitation:
Is the proposed research likely to lead to patentable or other commercially exploitable results? (please
give details)
3
18 May 2011
9
Financial support:
Amount Requested
£
Staff
Consumables
Equipment
Other
Total
Details of other contributions
10
£
Declaration and authorisation:
Applicants:
To my knowledge the project described here represents the ideas, concepts and writings of myself and coinvestigators and is not a modification of projects submitted by others elsewhere.
Signature of applicants
Name (Capitals)
Date
This application should be submitted by/through (i) the Head of Department and (ii) the officer who will
be responsible for administering any grant that may be awarded.
4
18 May 2011
Grantholder:
I confirm that I have read this application and that, if successful, the work will be accommodated and
administered in this Department/Institution in accordance with SIRN’s Conditions of a Research Grant. I accept
responsibility for the conduct of this project and funds awarded for it and shall immediately inform SIRN if
there is any indication of scientific misconduct or misuse of grant funds.
Head of Department:
Signature
Date
Title and full name (block capitals)
Department
Finance Office of Grantholder:
Signature
Date
Title and full name (block capitals)
Position held
Address
Postcode
Telephone no/ext
Email address
Fax no
When NHS Scotland Support Costs are identified, the R&D Officer(s) must sign the following:
This project application has been discussed with me/us (delete as appropriate) and I/we (delete as appropriate)
note the NHSScotland Support Costs associated with the application.
Signature(s)
Date(s)
Title(s) and full name(s) (block capitals)
Position(s) held
Address(es)
Postcode(s)
Telephone no(s)/ext(s)
Fax no(s)
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18 May 2011
Section 1
(Not more than 8 pages)
Proposed research project:
1
Title
2
Introduction (citing key references, searches used, etc.)
3
Results of any pilot studies
4
Aims
5
Research questions
6
Plan, methods, expertise available, statistical power
7
Timetable
8
Risk
9
Existing facilities
10
Justification of requirements
11
Research outcomes relating to NHS implementation potential
12
Dissemination
13
Key references
14
Relevant additional material
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18 May 2011
Section 2
Curriculum vitae of applicant(s)/proposed staff (if known): maximum 1 page per applicant.
(This form can be copied as necessary. Do not attach separate CVs)
Surname
Initials
Age
Title
Degrees etc.
Posts held (with dates)
Relevant recent publications (with title and reference)
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24 March 2011
Section 3
R&D Project Details Pro forma – Information for the National Research Register
1
Methodology: (please tick)
Clinical trial
Randomised controlled trial (specify comparison groups below)
Systematic review
Case-control study
Other (please specify in free text)
2
Sample group description (the notional population from which the sample is drawn for the purposes
of your study)
3
Outcome measure description (endpoints or factors used to evaluate health status, such as survival
discharge status or quality of life. Can also be a symptom.)
4
Project related website (the address for a web site which contains further related information for an
individual project)
SIRN is funded by the Scottish Government Health and Social Care Directorate
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24 March 2011