For office use only: APPLICATION ID.
__________________________
Diabetes Queensland
PhD Scholarship 2016
Application Form
Closing date: 5pm 2 November 2015. Late or incomplete applications will not be accepted.
Please read before completing

The closing date above shows the date on which electronic copies of applications are to reach Diabetes
Queensland.

This application form must be completed using 12 point Arial.

All sections of this application must be completed.

Applications not adhering to these guidelines will not be accepted.
Diabetes Queensland is the peak body for people with diabetes in Queensland - providing a single,
powerful and collective voice for the diabetes community. Diabetes Queensland supports more
than 217,000 registrants and 45,000 financial members in Queensland and works to improve the
lives of people affected by all types of diabetes.
One of Diabetes Queensland’s key strategies to improve lives is through research.
Correspondence
Diabetes Queensland
Research Program
GPO Box 9824
Brisbane Qld 4001
Email: research@diabetesqld.org.au
Telephone: 1300 136 588
Submitting Your Application
Please submit your full application as a pdf copy of the signed application to be emailed to
research@diabetesqld.org.au
The pdf copy of the application will be used to print copies of the application for the review panel. It is the
responsibility of the applicant to ensure that it is a true, full copy of the signed application. You will not be advised if it
is noted that your application is incomplete.
PhD Scholarship - Application Form
Page 1
Further Information
Please read the Diabetes Queensland Research Scholarship Application Guidelines before completing this application.
Available on www.diabetesqld.org.au
Click on Health Professionals and follow the links.
Checklist
Please ensure that electronic applications are submitted to Diabetes Queensland by the closing date. Applications must
be submitted via the Research office of your institution.
All application details and attachments must be included for your application to be considered.
Before you submit your application, please check:
 You are eligible to submit an application.
 The application is signed by ALL appropriate persons.
 Each section of the application is completed, which includes:
Please
Tick

Curriculum vitae of applicant (2 pages maximum)

Curriculum vitae of supervisor (2 pages maximum)

Academic transcripts of applicant

Referee reports (2 referees required)

Proof of Australian citizenship or permanent residency.

Human, animal or bio-safety ethics clearances if available (if your Scholarship is successful, you will be
required to supply clearance prior to funding being released).

Letter from your University indicating the start date of your PhD (or equivalent degree)
Electronic application must be submitted in 3 separate PDF files (no more than 5MB each).

File 1: Application Form

File 2: Supporting Documentation 1
o
A copy of passport, birth certificate or citizenship certificate (to show Nationality) OR Australian
permanent residency certificate OR evidence of submission for an Australian Permanent Resident
certificate attached
o
Ethics clearances if available (if your Scholarship is successful, you will be required to supply clearance
prior to funding being released).
o

Letter from your University indicating the start date of your PhD (or equivalent degree)
File 3: Supporting Documentation 2
o
CV of applicant (2 pages maximum)
o
CV of primary supervisor (2 pages maximum)
o
Academic transcripts of applicant
PhD Scholarship - Application Form
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o
Referee reports 1 & 2
You are providing your personal information to Diabetes Queensland as part of your PhD Scholarship Application.
Diabetes Queensland will only use your information for the purpose for which it is being collected. A copy of
Diabetes Queensland’s Privacy Policy is available on our website http://www.diabetesqld.org.au. To access or correct
your information or to make a complaint regarding your personal information please contact the Diabetes
Queensland Privacy Officer at PrivacyOfficer@diabetesqld.org.au or call 1300 136 588.
PhD Scholarship - Application Form
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Project
Scientific project title
Title
Ms
Mr
Dr
First name
Other (Please specify) ______________________________
Surname
Mobile
Telephone
Email
Administering institution
Name
Address
Where funds will be
administered
ABN
State
Appointments
Current
Appointment
Commencement Date
Current Salary
Current Institution
Citizenship/Immigration Status
State
Relevant document(s)
Australian Citizen
Attach copy of passport, birth certificate or citizenship certificate.
Permanent Residence
A copy of an Australian permanent resident certificate or evidence of
submission for an Australian Permanent Resident certificate attached.
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Study commencement & previous qualifications
PhD Commencement
Have you Commenced your PhD?

If you have completed the equivalent of more that 1 year of your PhD at 1.0
FTE at the closing date of application, you are ineligible to apply (e.g. 1 year
@ 1.0 FTE = 2 years @ 0.5 FTE).
Yes

You must include a Letter from your University indicating the start date of
your PhD
No
If you have already started your PhD, please indicate what your FTE has been to
date (e.g. 1.0 FTE = Full Time, 0.5 FTE = Half of Full Time)
___________FTE
Please nominate either the date you started your PhD or your intended start
date
dd/mm/yyyy
If you are successful for a Diabetes Queensland Scholarship, when would you
like to start your tenure?
dd/mm/yyyy
Please confirm you will be studying full-time
Yes
Summary of academic and professional qualifications:
Year
Degree
Applicant’s Curriculum Vitae
Please attach your CV (2 pages maximum)
Conferring Institution
Attached
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Primary supervisor
Title
Dr
A/Prof
First name
Prof
Other (Please Specify) ___________________________________
Surname
Qualifications
Institution
Department
Telephone
Mobile
Email
Attached
Primary Supervisor’s Curriculum Vitae
Please attach primary supervisor’s CV (2 pages maximum)
Referees
NAME
EMAIL
REFEREE 1
REFEREE 2
PLEASE NOTE: Referee reports must be submitted prior to the closing date. It is an applicant’s responsibility to ensure
referee reports are submitted on time. Late referee reports will not be accepted under any circumstances.
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Track record
Include publications which have been published, or accepted for publication, in refereed journals. The list must be
numbered and each reference must include authors, journal name, journal title, year and page numbers. Please add impact
factors and citations for each of your publications as well as the relative ranking of each journal within its field (if available).
Please indicate the role you had in each of these publications.
Papers:
Abstracts:
Describe your overall career aspirations In particular, focus on your commitment to research, diabetes research and future
career plans. (Half page maximum)
Provide details of significant scientific and community achievements, awards, administrative, teaching, research, community
and/or other professional experience. (One page maximum)
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Other funding bodies
YES
No
Is this application also under review by any other funding body, or do you intend to submit this application
to any other funding body? If YES, please provide details
Details of Application
Funding Body
(include award category & reference number if known)
Please suggest organisations that may be interested in co-funding this application.
Note: This will not affect the funding outcome.
Clearance requirements
Research funded by Diabetes Queensland shall be conducted in accordance with the Australian Code for the Responsible
Conduct of Research (2007). Clearances for research that involves any of the following shall be obtained from the
appropriate Ethics Committee and/or Biosafety Committee and submitted to Diabetes Queensland Research Office before
funding is released.
YES / NO
Does this project involve experiments on human subjects?
Does this project involve experiments on animals?
Does this project involve genetic manipulation of organisms or the use of radioactive substances,
recombinant DNA, potent teratogens, carcinogens or toxic chemicals?
By completing and submitting this application, I acknowledge that I will abide by the Australian Code for the Responsible
Conduct of Research (2007), obtaining all ethics approvals and clearances as are necessary to complete my project as outlined
in this application. I further consent to inform Diabetes Queensland of all applications for ethics clearance and confirm I will
forward all approvals as they are received (or within 30 days of receiving them).
I also understand that failure to provide these clearances as they are required or failure to secure ethics approval for my
project may result in my funding being suspended until such time as clearances have been submitted to Diabetes
Queensland.
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Signatures
(a)
Applicant & Supervisor

I certify that all details given in the application are correct and I agree to carry out the project in accordance with
Diabetes Queensland’s current Funding Deeds for Scholarships and in accordance with the principles of the Australian
Code for the Responsible Conduct of Research (2007).

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 my application from the review process.

I acknowledge that all supporting documentation has been provided with this application. I understand my
application will not be eligible for consideration by Diabetes Queensland if this application is incomplete or does not
include the required documentation.
Applicant
Full Name
Signature
Date
___/___/15
Date
___/___/15
Supervisor
Full Name
Signature
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 Funding Deeds for Diabetes Queensland Scholarships.
Title
Full Name
Position
Department
Signature
Institution
Date
___/___/15
PhD Scholarship - Application Form
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Verification by Research Administrative Officer

I 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 and documentation are correct and included with this application at
the time of lodgement with Diabetes Queensland.

In addition, I verify 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).
Title
Full Name
Position
Department
Institution
Phone
Fax
Email
Signature
Date
___/___/15
PhD Scholarship - Application Form
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ATTACHMENT ONE
1. Simplified project title
This should be suitable for release to the media or for general publication
2. Project synopsis
Describe the overall aims of the research and expected diabetes outcomes. AVOID the use of technical terms. This should be
suitable for release to the media or for general publication (15 lines maximum).
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3. Project significance
(A) Specific Aims – List the specific aims and hypotheses to be tested (15 lines maximum).
(b) Potential Outcomes - How will your research contribute to the Diabetes Queensland mission of to improve the lives of
people affected by all types of diabetes. (15 lines maximum)
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4. Research plan & figures
(A) Applicants may provide up to TWO PAGES MAXIMUM under this heading, including references. Figures must be included
within the two pages.
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(B) Briefly describe how the host institution can support your research – both as outlined in your research plan and in your
research career development (15 lines maximum).
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