Office Use Only – Application Ref IDTE/03/16/
NIHR INFRASTRUCTURE DOCTORAL TRAINING EXCHANGE
SCHEME
NIHR INFRASTRUCTURE DOCTORAL TRAINING EXCHANGE SCHEME 2016
APPLICATION FORM
Applicant Name:
Contact Tel:
Email:
Published January 2016
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SECTION A – APPLICATION SUMMARY
Ai. Trainee Details
Surname
Forename
Title
Professional background please select from drop down lists
Medical Specialties:
A–G
*****
Medical Specialties:
H–O
*****
Medical Specialties:
P–U
*****
Dental Specialties
*****
Nurse/Midwife
*****
Allied Health Professional
*****
Other Healthcare Professionals
*****
******
*****
if other please specify
Not a Health Professional
*****
if other please specify
Professional Body Registration If you are registered with the regulatory body or council of your profession please
indicate which you are registered with
Exchange Title
Proposed start date
******
Aii. Exchange Host Details
NIHR Infrastructure
Organisation
Department
Address 1
Contact
Address 2
Address 3
Town/City
Address 5
Postcode
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Aiii Home Institution Details
Job title
Department
Contact
Organisation
Address 1
Address 2
Contact
Phone No
Contact
email
Address 3
Town/City
Address 5
Postcode
Applicant correspondence address if different from above
Address 1
Phone No
Address 2
Email
Address 3
Town/City
Address 5
Postcode
Published January 2016
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PART B – TRAINEE EXPERIENCE
Overview of experience to date (100 words max)
PART C – EXCHANGE HOST ORGANISATION AND SUPERVISOR
Contact details
Surname
Forename
Title
******
Job title
Address 1
Contact
Address 2
Phone No
Address 3
email
Town/City
Address 5
Postcode
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PART D – PROPOSED EXCHANGE TRAINING PROGRAMME
Di. Please outline the research you plan to undertake during your exchange, and describe how it
will contribute to your PhD (300 words max)
Dii. Please provide details of the host supervisor and how they will support the applicant (300
words max)
Diii. Please justify the resources requested for the exchange
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PART E - DECLARATIONS AND SIGNATURES
Applicant
I confirm that I have secured all necessary licences and ethical approvals in relation to the research and will abide
by the terms of those licences and approvals in carrying out the research.
I confirm that I have read the NIHR Carbon Reduction Guidelines and, where possible, taken steps to reduce the
carbon emissions generated by this research.
I confirm that the information regarding the current status of my research doctorate is complete and accurate.
I undertake to conduct the research according to such guidelines for good research practice as the Host
Organisation may from time to time laydown according to the NIHR research governance framework and the
guidelines set out in ‘Good Clinical Practice in MRC-funded Trials’ (MRC 1998).
In completing this, I declare that, to the best of my knowledge, the information provided in this application, is true,
accurate and complete. I have read the Guidance Notes and agree to accept the process by which an application is
assessed and agree to abide by the conditions under which an award may be granted. I agree that the NIHR may
hold and process, by computer or otherwise, personal and other data supplied with this application and, if
successful, additional data provided during the fellowship award.
I understand that the application will be shared with members of the Expert Review Panel and may be sent for
external peer review.
Name (please print)
Published January 2016
Signature
Date (dd/mm/yyyy)
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Home Organisation – Primary Supervisor
As Primary Supervisor of the Applicant at the home institution, I approve this application and will support the
candidate’s programme of activities as detailed in this application. The applicant is eligible for and capable of taking
up this award. I confirm that the candidate will be eligible, for the duration of the award, to live and work in the UK.
Name:
Job Title:
Email Address:
Signature:
Date:(dd/mm/yy)
Home Organisation – NIHR Training Lead
As NIHR Training Lead of the home employing institution, I have read the Guidance Notes.
Name:
Job Title:
Email Address:
Signature:
Date:(dd/mm/yy)
Host Organisation – Supervisor
As host organisation supervisor, I have read the Guidance Notes. I approve this application and will support the
candidate’s programme of activities as detailed in this application.
Name:
Job Title:
Email Address:
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Signature:
Date:(dd/mm/yy)
Published January 2016
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PART F – NIHR INFRASTRUCTURE TRAINING LEAD STATEMENT OF SUPPORT (400 words max).
Name
Job title
Signature
PART G – DEPARTMENT OF HEALTH MONITORING INFORMATION
How did you become aware of this scheme? (NB: if from a colleague or advisor, it would also be helpful to know
their source of information)
If ‘Other’ please give brief description below
*****
UKCRC Health Categories - Select ONE or TWO Health categories
First category
*****
Second (optional) category
*****
Published January 2016
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UKCRC Research Activities - Only select ONE or TWO research activities – see guidance notes for details
Underpinning Research
1.1 Normal biological development and functioning
Aetiology
2.1 Biological and endogenous factors
1.2 Psychological and socioeconomic processes
2.2 Factors relating to physical environment
1.3 Chemical and physical sciences
2.3 Psychological social and economic factors
1.4 Methodologies and measurements
2.4 Surveillance and distribution
1.5 Resources and infrastructure (underpinning)
2.5 Research design and methodologies
(aetiology)
2.6 Resources and infrastructure (aetiology)
Prevention of Disease and Conditions and Promotion of
Well-Being
Detection, Screening and Diagnosis
3.1 Primary prevention interventions to modify
behaviours or promote well-being
3.2 Interventions to alter physical and biological
environmental risks
4.1 Discovery and preclinical testing of
markers and technologies
3.3 Nutrition and chemoprevention
4.3 Influences and impact
3.4 Vaccines
4.4 Population screening
3.5 Resources and infrastructure (prevention)
4.5 Resources and infrastructure (detection)
Development of Treatments and Therapeutic
Interventions
Evaluation of Treatments and Therapeutic
Interventions
5.1 Pharmaceuticals
6.1 Pharmaceuticals
5.2 Cellular and gene therapies
6.2 Cellular and gene therapies
5.3 Medical devices
6.3 Medical devices
5.4 Surgery
6.4 Surgery
5.5 Radiotherapy
6.5 Radiotherapy
5.6 Psychological and behavioural
6.6 Psychological and behavioural
5.7 Physical
6.7 Physical
5.8 Complementary
6.8 Complementary
5.9 Resources and infrastructure (development of
treatments)
6.9 Resources and infrastructure (development
of treatments)
Management of Diseases and Conditions
Health and Social Care Services Research
7.1 Individual care needs
8.1 Organisation and delivery of services
Published January 2016
4.2 Evaluation of markers and technologies
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7.2 End of life care
8.2 Health and welfare economics
7.3 Management and decision making
8.3 Policy ethics and research governance
7.4 Resources and infrastructure (disease
management)
8.4 Research design and methodologies
8.5 Resources and infrastructure (disease
management)
The Department of Health, National Institute for Health Research (DH NIHR) is the Data Controller under the Data
Protection Act 1998 (‘the Act’). Applicants for funding should be aware that information contained in this application
might be shared with other DH NIHR bodies for the purposes of statistical analysis and other DH NIHR
management purposes, including targeted communications with selected groups of researchers. Applicants may be
assured that DH NIHR is committed to protecting privacy and to processing all personal information in a manner
that meets the requirements of the Act.
Published January 2016
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