NMRC Research Training Fellowship/NRF-MOH Healthcare Research Scholarship Request for Seed Funding (S$30,000) All information is treated with confidence. The information is furnished to the National Medical Research Council with the understanding that it shall be used or disclosed for evaluation, reference and reporting purposes. The purpose of this seed funding is to assist the Fellow/Scholar who has completed training under one of the above programmes, to start a research project using knowledge attained during the training. Period of seed funding commences upon the fellow’s return to the institution and is valid for a period of up to 2 years from the award date. There will be a call for submission of an annual report and a final report every March for the funded NMRC Research Training Fellow, and every September for the funded NRF-MOH Healthcare Research Scholar respectively. Please ensure that ALL sections of this Form are completed. 1. INFORMATION OF APPLICANT Name of Applicant (as in the NRIC) Surname: Given Name: Academic Grade (E.g., Assistant Professor, Associate Professor, Professor) Clinical Grade (E.g., Medical Officer, Registrar, Associate Consultant, Consultant, Senior Consultant) Department / Institution Address of Employer Type of Fellowship/Scholarship Awarded NMRC Research Training Fellowship NRF-MOH Healthcare Research Scholarship (PhD) Period of Research Training Start Date: (dd/mm/yyyy) Completion Date: (dd/mm/yyyy) Type of Training: Full-time local post-graduate training (PhD/MSc/MPH/____ )* Part-time local post-graduate training (PhD/MSc/MPH/____ )* Full-time overseas research attachment leading to a graduate degree (PhD/MSc/MPH/____ )* Part-time overseas research attachment leading to a graduate degree (PhD/MSc/MPH/____ )* Full-time overseas research attachment not leading to a degree 2. PROPOSED RESEARCH PROJECT (i) Research Project Title: (ii) Key words: Please provide a maximum of 6 key words related to the research project. (iii) Detailed Research Proposal: Please also attach details of the research project, including: Abstract (200 to 300 words) Introduction Aims Hypotheses Methodology The above should be in presented in no longer than 10 pages. References should be attached at the end of the proposal and does not count towards the page limit. Please present the research proposal on A4-sized paper, 1-inched margins, single-line spacing and size 12 Times New Roman font. (iv) Field of Research / Health Category: Please select up to 5 categories from the following. Blood Cancer Cardiovascular Congenital Disorders Ear Eye Infection Inflammatory and Immune System Injuries and Accidents Metabolic and Endocrine Musculoskeletal Neurological Oral and Gastrointestinal Renal and Urogenital Reproductive Health and Childbirth Respiratory Skin Stroke Generic Health Relevance Other : _________________________ (v) Industry link: Is your project industry-linked? Yes No If yes, please give a description on how your project is industry-linked: (E.g. name of company, your involvement) (vi) Information on Research Mentor: Name: Email: Designation: Phone: Department: Institution: Field of Research / Health Category: [To indicate only if different from section 2(v)] Please select up to 5 categories from the following. Blood Cancer Cardiovascular Congenital Disorders Ear Eye Infection Inflammatory and Immune System Injuries and Accidents Metabolic and Endocrine Musculoskeletal Neurological Oral and Gastrointestinal Renal and Urogenital Reproductive Health and Childbirth Respiratory Skin Stroke Generic Health Relevance Other : _________________________ Please attach the following: Letter of undertaking from the proposed Research Mentor CV [to include details of current and pending funding; i.e. name of agency, number of grants held, grant title, role (e.g. PI or co-PI), grant duration and the awarded budget] Training record of the Research Mentor (e.g., number of fellows previously trained and number of fellows currently in training) 3. ETHICAL CONSIDERATION AND CONTAINMENT Fund disbursement is subjected to ethics approval if the project involves any of the below. Please tick accordingly if project involves any of the following: Item requiring ethics approval: a) Human Subject b) Use of Human/Animal Tissues or Cells from Primary Donors (i.e. subject/volunteers recruited for project) c) Use of Commercially Available Human/Animal Tissues or Cells d) Animal Experimentation e) Requirement for Containment f) Multi-centre trial(s) (If yes, please state all participating institutions/centres : ) A copy of the ethics approval for each declared item is attached: Yes No Please declare the participating institutions where study requiring ethics approval is conducted: 4a. BUDGET CONSIDERATION Please provide and estimation of budget under each category. For NMRC Research Training Fellows, items must be in line with NMRC general fund guidelines. For NRF-MOH Healthcare Research Scholars, items must be in line with National Research Foundation (NRF) and NMRC general fund guidelines; and should there be discrepancies, guidelines by NRF will prevail. Category FY2011 FY20__ FY20__ Total (S$) Manpower Salary and costs should be as per Human Resource policies of your Institution. Equipment Other Operating Expenses (OOE) This category covers expenses such as the purchase of animals, consumables, laboratory manuals, literature search, maintenance of equipment and conference travel for a presentation related to the project. Grand Total: (S$) 4B. PROTECTED TIME (Specific for NRF-MOH Healthcare Research Scholars only) NMRC will support salary up to a total of $60,000 based on the protected time for research required by applicant upon return. Protected time for research required by applicant: FTE* / Hours per week * Please enter FTE to 1 decimal place. The total work hours per week for a five-day week is 40 hours; 0.1 FTE is equivalent to 4 hours. 5. DECLARATION BY APPLICANT I DECLARE that, to the best of my knowledge, the information I have provided on this form is true, accurate and complete. I consent to the NMRC holding and using the data on this application form together with other documents attached for the purpose of administering and reviewing my application. I agree that such data may be made available to those who reasonably need to know within the NMRC and NMRCappointed reviewers. ___________________________________ Signature of Applicant ______________________ Date (dd/mm/yyyy) 6. ENDORSEMENT BY HEAD OF DEPARTMENT I SUPPORT the above application for the seed funding. The Department will protect the Fellow’s/Scholar’s time; provide him/her with the necessary support, facilities and equipment to enable him/her to continue his/her development in clinical/biomedical research as declared in the application and/or agreement under the Fellowship/Scholarship. ___________________________________ Signature of Head of Dept ______________________ Date Name: 7. ENDORSEMENT BY THE INSTITUTION / MEDICAL SCHOOL I SUPPORT the above application for the seed funding. The Institution will protect the Fellow’s/Scholar’s time; provide him/her with the necessary support, facilities and equipment to enable him/her to continue his/her development in clinical/biomedical research as declared in the application and/or agreement under the Fellowship/Scholarship. ___________________________________ Signature of Director/CEO of Institution OR Dean of Medical School* Name: * Please delete where appropriate ______________________ Date