Application Form
The Jane O’Connell Research Scholarship
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The “Jane O’Connell Research Scholarship” commences in 2015 in honour of
Dr Jane O’Connell, one of the first endorsed Nurse Practitioners in Australia.
The scholarship recognises the work done by Jane during the establishment and development of
the nurse practitioner role in New South Wales.
This research scholarship is up to the value of $5000 (1 x $5000 or 2 x $2500).
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Eligibility criteria
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Australian permanent resident
Endorsed nurse practitioner with AHPRA
Practising in a nurse practitioner role (at least 0.8FTE)
Current financial member of the Australian College of Nurse Practitioners
The award is used for research into nurse practitioner practice
Document checklist
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Application form completed in full
Curriculum vitae supplied by the applicant
o Please include a short and concise CV which includes your qualifications,
employment history and relevant research experience (including publications)
Research proposal attached
If proposing to undertake research that requires direct contact with patients and/or access
to personal information, you may be required to seek approval from an Ethics Committee
Referees
Two professional referees are required to support this application.
The ACNP may contact these referees as part of the overall assessment of this application.
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Selection Criteria
Applicants must address the selection criteria and declaration included in this application form.
Preference will be given to research proposals that evaluate the outcomes of nurse practitioner
practice.
Applications close 4 December 2015.
J.OConnell Research Scholarship Oct 2015
Application Form
The Jane O’Connell Research Scholarship
Section 1: Applicant Details
Preferred title
First Name
Last Name
Mailing Address
Email Address
Phone Home
Phone Work
Phone Mobile
AHPRA Registration No.
Current Employer
Current Position
* Please provide a Curriculum Vitae to support this application
Section 2: Membership of the Australian College of Nurse Practitioners (ACNP)
Are you a current financial member of the ACNP?
Yes
No
Are you a Fellow of the ACNP?
Yes
No
Membership Number
J.OConnell Research Scholarship Oct 2015
Application Form
The Jane O’Connell Research Scholarship
Section 3: Referees
Referee 1:
Preferred Title
First Name
Last Name
Email Address
Phone Work
Phone Mobile
Current Position
Relationship to you
Referee 2:
Preferred Title
First Name
Last Name
Email Address
Phone Work
Phone Mobile
Current Position
Relationship to you
J.OConnell Research Scholarship Oct 2015
Application Form
The Jane O’Connell Research Scholarship
Section 4: Selection Criteria
4.1
Please attach an outline of your research / project proposal (1000 words maximum)
Identify how this will add to the body of knowledge on outcomes of nurse
practitioner practice in Australia.
4.2
Does your research require approval from an Ethics Committee?
YES
NO
If yes, when would you anticipate receiving the approval?
Note: A copy will need to be provided to ACNP
4.3
Discuss how you plan to disseminate the findings of your research (500 words max)
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Section 5: Terms and Conditions
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Applications must be received on this form and must be completed in full
Late or incomplete applications will not be accepted
Applications are competitive and ACNP reserves the right to withdraw the award should
conditions not be satisfied
The ACNP reserves the right to not make an offer of an award
The ACNP will undertake assessment of all applications and the decision of ACNP will be
final
The successful applicant/s are required to submit brief progress reports to ACNP every
three (3) months
ACNP and the Jane O’Connell Research Scholarship will be acknowledged in any
publication or presentation resulting from this funding support
Outcomes will be presented at the ACNP National Conference
ACNP reserves the right to publish information about the research scholarship and
successful applicants in their medium of choice
J.OConnell Research Scholarship Oct 2015
Application Form
The Jane O’Connell Research Scholarship
Section 6: Declaration
A. I declare that:
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Information that I have supplied on this application form is true and correct
I will advise ACNP in writing of any change in my circumstances
B. I understand that:
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Information on this application form is collected for the purposes of assessing
Eligibility and for awarding of the Jane O’Connell Research Scholarship
Information on this application form may be used to promote the Jane O’Connell
Research Scholarship and the successful application.
If approval is required from an Ethics Committee, a copy of the approval will need
to be provided to ACNP.
I agree to the terms and conditions of the Jane O’Connell Research Scholarship
Name:
Signature:
Date:
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Submission:
Application via email is the preferred method of submission.
Please attach the requested supporting documents including a CV and outline of your
Research/Project Proposal.
Submit your application to secretariat@acnp.org.au
For further information please contact
Grainne Lowe
ACNP Vice President and Head of Research
vicepresident@acnp.org.au
J.OConnell Research Scholarship Oct 2015