Please complete this form using a standard sized font (no smaller than 10 point)
1 Project title (not more than 25 words):
2
Project summary (not more than 150 words) :
Dates:
Duration of project (months)
Proposed start date
Proposed finish date
3 Chief Investigator:
Title and full name
Position Institution
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4
Applicant’s details:
Title and full name
(Principal applicant)
5
Full address
Telephone no/ext
Organisation
Co-applicants:
Title and full name
(Co-applicant)
Full address
Telephone no/ext
Fax no
Fax no
Department
E-mail address
E-mail address
Organisation Department
Title and full name
(Co-applicant)
Full address
Telephone no/ext
Organisation
Title and full name
(Co-applicant)
Full address
Telephone no/ext
Fax no
Fax no
Department
E-mail address
E-mail address
Position
Position
Position
Hours per week
Hours per week
Hours per week
Hours per week
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Organisation Department Position
6 Permissions:
Clinical Trial Authorisation (CTA) details for Trials subject to the Clinical Trial Regulations:
Ethical approval: (please tick)
Attached Not Required
Animals: (please tick)
Requested/To be Requested
Not required
7 Support:
Requested/To be Requested
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)
Does the project involve collaboration with industry? (please give details)
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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.
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17 September 2012

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. The staff gradings and salaries proposed are correct and in accordance with the normal practice of this Institution. 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 )
Finance Office of Grantholder:
Signature
Department
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)
Address(es)
Postcode(s)
Telephone no(s)/ext(s)
Position(s) held
Fax no(s)
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Proposed research project (not more than 8 pages):
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 Translation
12 Public engagement in science
13 Dissemination
14 Key references
15 Relevant additional material
Section 1
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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 Title
Degrees etc.
Posts held (with dates)
Relevant recent publications (with title and reference)
Section 2
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Section 3
R&D Project Details Pro forma
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
Describe the notional population from which your study sample will be drawn.
3 Outcome measure description
Endpoints or factors used to evaluate health status, such as survival discharge status or quality of life, reduction
in blood pressure, etc.
4 Project related website
If there is a web site which contains further related information for an individual project, provide the URL.
SIRN is funded by the Scottish Government Health and Social Care Directorates
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