Application Form:
Round 1- 2015
1. APPLICANT PERSONAL DETAILS
Title: _______________________________________________________________
Family Name: _______________________________________________________
Given Names: ________________________________________________________
Dob: ________________________________________________________________
Address: ____________________________________________________________
Phone Number: ______________________________________________________
Email Address: ______________________________________________________
2. APPLICANT WORK DETAILS
Current Employer: ___________________Department: _______________________
Current Position/Title: __________________________________ FTE: ____________
Discipline/Profession: ___________________________________________________
Current Employment Status: Casual/Temp/Perm: _______P/T or F/T: ____________
Line Manager- Name: _______________________Title: _______________________
Phone No: __________________________Email: ____________________________
Department Manager -Name: ____________________Title: ____________________
Phone No: __________________________Email: ____________________________
Position nominated to be replaced by fellowship: ___________________________
FTE to be dedicated to Fellowship eg (0.8 FTE) ___________________________

3. PROPOSED RESEARCH PROJECT:
3.1 Short Project Title:
3.2 Lay Description of Proposed Research (Limit 100 Words)
3.3 Chief Investigators.
List names, institutions positions of all Chief Investigators in order of contribution.
3.4 Role and Contribution to Research Project. (Limit one page)
Describe your role within the research project, including your specific responsibilities and contribution toward the research design, activities and outcomes. Describe your involvement in areas such as development of the research plan, development and implementation of methods and techniques, validation and analysis of data, reports and assessment of project for translation into improved health outcomes.
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3.5 Significance of the Project.
Include the significance of the project to the community and HNE Health (for example improved health outcomes, efficient/cost effective healthcare delivery).
Consideration should also be given to the potential for translation of research evidence into clinical practice and possible implementation of the research outcomes. (Limit to one page)
4. RESEARCH PROJECT:
Please provide full details of the research plan, for example: a) research question(s), aims, hypothesis, methods, techniques, statistical considerations, target group; and b) anticipated key milestones against the project’s timeline. (Max of five pages)
5. RESEARCH GOVERNANCE REQUIREMENTS
Provide details regarding the research governance requirements for the proposed project.
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6. RESEARCH FUNDING
6.1 Has the proposed project, or closely related projects received funding previously? If so, please provide brief details including funding agency, amount etc.
Is the project dependent upon the receipt of the Clinical Research Fellowship funding.
6.2 Is the proposed project currently being considered for funding by any other funding agencies? If so please provide details.
7. BUDGET
Please provide a budget proposal for the duration of the Fellowship in accordance with the NSW Health clinician remuneration award. In addition please adhere to the following criteria:

Please calculate using a Fellowship Commencement Date of 1 st January 2016.

Award/Agreement salary and allowance rate increases are calculated using the published rate, or where rates are not published, a rate of 4% is to be used.

NO allowances such as overtime or on-call are to be claimed as part of the
Fellowship.

Research costs may include minor equipment, consumables and other expenses with the total amount not exceeding $5,000.
 The maximum value of the Fellowship shall be $150,000 per annum, with the actual amount offered being at the discretion of the HNE Health Research
Innovation Advisory Council.
 Budgets must be calculated accurately, with remuneration costs verified by the applicant’s department business manager, as requests for additional funding will not be approved.
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AWARD AGREEMENT NAME
( Award/Agreement applicable to applicants NSW
Health Clinician Role)
AWARD/AGREEMENT INCREASE DATE
(Day month that salary/allowance rates increase in the relevant Award/Agreement)
SALARY DETAILS
(Salary classification description, increment point
& full-time annual $ rate as at 1/1/16)
SALARY INCREMENT DATE
(Applicant salary increment day & month, if applicable)
ALLOWANCE DETAILS
(Allowance description and full-time annual $ rate, as at 1/1/16, for each applicable allowance)
BUDGET ITEMS YEAR 1
(2016)
YEAR 2
(2017)
YEAR 3
(2018)
TOTAL
Salary Costs
(Include award/agreement increases, applicant salary increments and adjust for FTE requested)
Allowance Costs
)Include award/agreement increases and adjust for FTE requested)
Salary On-Costs
(20% applied to salary and allowances costs)
Minor Equipment
Consumables
Other Expenses
TOTAL
8. BUDGET JUSTIFICATION
Please explain the FTE and the research cost requirements. Attach quotations for any equipment and other items as appropriate.
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9. APPLICANT CERTIFICATION a) I declare that the information supplied by me on this form is complete, true and correct. b) I confirm that during the period of the Fellowship, I will not be in receipt of more than 0.2 FTE paid time for clinical duties as it relates to the research project undertaken in the course of the fellowship. c) I agree to abide by the HNE Health’s guidelines and conditions for applicants in receipt of the HNE Health Clinical Research Fellowship. d) I understand and agree that a claim will not be made on the NSW Ministry of
Health, HNE Health and/or HNE Health Research Innovation and Partnership
Unit to cover over expenditure of budget.
FULL NAME:
SIGNATURE: DATE:
10. LINE MANAGER CERTIFICATION/AGREEMENT a) I confirm that the applicant is currently employed by HNE Health as a clinician, and that if nominating to do so, the applicant may continue to work in this capacity for no more than 0.2 FTE of this position for the course of the
Fellowship. b) I confirm that the applicant maybe released from their substantive clinical position for not less than 0.8 FTE, and that their vacated post will be adequately back-filled (if applicable) for the duration of the Fellowship c) I confirm that the business manager of the department has verified the budget costs in this application.
FULL NAME:
Position/Title:
SIGNATURE: DATE:
11. DEPARTMENT HEAD CERTIFICATION/AGREEMENT a) I confirm that the applicant is currently employed by HNE Health as a clinician, and that if nominating to do so, the applicant may continue to work in this capacity for no more than 0.2 FTE of this position for the course of the
Fellowship. b) I confirm that the applicant maybe released from their substantive clinical position for not less than 0.8 FTE, and that their vacated post will be adequately back-filled (if applicable) for the duration of the Fellowship
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c) I confirm that the business manager of the department has verified the budget costs in this application.
FULL NAME:
Position/Title
SIGNATURE: DATE:
12. TEAM LEADER CERTIFICATION/AGREEMENT
I confirm that adequate infrastructure and research support shall be provided to the applicant within the research group for the term of the Fellowship.
FULL NAME:
POSITION/TITLE:
SIGNATURE: DATE:
13. PRINCIPAL SUPERVISOR CERTIFICATION/AGREEMENT
I certify that I have read the application and confirm that the applicant shall receive guidance and support in relation to the proposed project for the term of their fellowship.
FULL NAME:
POSITION/TITLE:
SIGNATURE: DATE:
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14. CHECK LIST
The following check list is provided to guide you in submitting a completed application. (Please note incomplete applications will not be assessed) Please check to ensure you have attached;
1.
Your current and updated Curriculum Vitae ☐
2.
Curriculum Vitae of Project Team Leader of the Research Clinical Unit
3.
4.
Curriculum Vitae of Principal Supervisor/Mentor
Line Manager Certification/Agreement
☐
☐
☐
5.
6.
Department Head Certification/Agreement
Project Team Leader of Research Clinical Unit- Certification/Agreement
☐
☐
7.
Principal Supervisor/Mentor Certification/Agreement ☐
8.
Budget outline for the proposed project and checked the figures with the ☐ business manager
9.
Informed the HNE CRF Selection Committee in writing of any special requirements or provisions in relation to intellectual property or confidential material contained in the application ☐
10.
Emailed a copy of the completed application (including all CV’s) in pdf ☐
format (converted from word document) to:
HNELHD-RSDO@hnehealth.nsw.gov.au
by 5 pm 12 October 2015
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