LOTTERY
HEALTH RESEARCH
Post-doctoral fellowships and PhD scholarships
Te Tahua Rangahau Hauora
Grant Application and Declaration Form
Before you start filling out this form, read carefully the information regarding the Lottery Health Research on www.communitymatters.govt.nz
to help you decide whether you are eligible for a Lottery Health Research grant.
Please answer every question. Incomplete or late applications are unlikely to be accepted. An application will be incomplete if all additional
information requested is not attached. Do not alter margins. Please observe word and page restrictions. Submit your application in MS Word or
editable PDF format attached to an email to lhr@dia.govt.nz by 4.00pm on Wednesday 27 August 2014.
SECTION A: GENERAL INFORMATION
A1.
What is your name?
Name
A2.
Host institution
Type here
A3.
A4.
Supervisor/mentor
Name
Position
Department/Organisation
Type here
Type here
Type here
Title of translational research
Type here
A5.
A6.
What is the total amount you’re applying for? (Note: the maximum available for PhD scholarships is $45,000 per year for a maximum of
three years and for Post-Doctoral fellowships $75,000 per year for a maximum of two years)
Number of years:
Type here
Total amount:
Type here
Are you a permanent New Zealand resident?
YES
A7.
NO
Are you eligible to commence a Post-doctoral fellowship in the 2015 academic year?
YES
NO
If you are applying for a Post-Doctoral fellowship, please complete the CV template form and attach your academic transcripts.
If you are applying for a PhD scholarship, please attach your academic transcripts.
Note: All overseas academic records must be translated to the New Zealand equivalent by the host institution.
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SECTION B: TRANSLATIONAL RESEARCH PROJECT
B1
B2.
Research proposal
Aims and objectives of translational research
Type here (100 words maximum)
Translational research design and methods
Type here (500 words maximum)
Key milestones of the translational research
Type here (200 words maximum)
What is the health significance of the translational research? How
does this translational research meet the Lottery Health Research
priorities, particularly community benefit?
Type here (300 words maximum)
What support will the host institution provide for the PhD scholarship or Post-Doctoral fellowship? (Note: The host institution is expected
to contribute to the PhD student’s/Post-doctoral fellow’s translational research project by providing accommodation, supervision,
administration of a grant, etc.)
Type here
B3.
If you are applying for a post-doctoral fellowship, is the post-doctoral research project funded? If yes, who is funding it? If no, who will
fund it?
Type here
B4.
Does the translational research require Ethical Approval?
YES
B5.
Does the translational research involve the development or importation of an organism modified through the use of recombinant DNA
techniques, for example, a GMO?
YES
B6.
NO
NO
Please describe how the translational research findings will be made publicly available beyond the normal scientific outlets. (Note:
Findings from translational research projects funded by a Lottery grant must be made freely available. Please describe how you will do
this, for example through publications or seminars for professionals or the general public.)
Type here
SECTION C: ADDITIONAL INFORMATION
C1.
Please write below any additional information to support your application.
Type here
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SECTION D: REFEREES UNACCEPTABLE TO APPLICANTS
D1.
The Committee may request referees to assist with making a decision on this application. Please give up to two individuals or research
groups you DO NOT WANT the Committee to request a referee report from.
Note: An individual or research group may be unacceptable as referees because: 1) they are competitors, 2) there is a conflict
of interest, 3) there are commercial sensitivity issues.
Name
Type here
Organisation/
Location
Type here
Name
Type here
Organisation/
Location
Type here
SECTION E: COMMUNITY / SECTOR BENEFITS
E1.
Which of the following age groups will your project/service primarily provide for?
Select the appropriate box(es)
12 years and under
E2.
13-25 years
26-64 years
65 years and over
All ages
Is your translational research project focussed on a particular ethnic group (See Note A)
YES
NO
If yes, which main ethnic group will most benefit from the project/service being provided as a result of the Lottery grant you are applying
for? (See Note A)
Type here
Which specific ethnic group within this main group will most benefit from the project/service being provided as a result of the Lottery grant
you are applying for? (See Note A)
Type here
E3.
Which geographic area does the host institution operate mostly in? (please refer to Note B when answering this question).
Which region will your project/service primarily provide for? (See Note B)
Type here
Which local authority area or areas, within this region, will your project/service provide for? (If your project provides services in all local
authorities within this region, please write ‘all’.) (See Note B)
Type here
E4.
Please select up to three sectors from the list below that you believe will most benefit from services being provided as a result of a Lottery
grant:
People with disabilities
Youth
Family violence prevention
Family/whānau
Women
Older people
New migrants/refugees
Unemployed
No specific sector
Youth at risk/disadvantaged
Children
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SECTION F: CONTACT DETAILS
Host Institution Details
F1.
What is the name, location and physical address of the host institution? (i.e. university campus details)
Name
Name
Location
Location
Physical
Physical address
Suburb
Suburb
City / town
City / town
Postcode
Postcode
Contact person
Name
Position
Position
Daytime phone
Prefix Phone number
Email
Email address
DECLARATION
PhD candidate / Post-doctoral fellow:
I solemnly declare that all the details contained in all sections of this application are true and correct to the best of my knowledge, that the
translational research will be undertaken according to the ethical principles set out by the Health Research Council of New Zealand, and that the
results of any translational research funded will not be used for any commercial purposes and will be publicly available with no limitations.
First name
Type here
Signature
Last name
Type here
Date
Type here
Head of Department/Section Head, and financial authority (e.g. Finance Registrar/Head of Finance/Treasurer of Trust):
I solemnly declare that all the details contained in all sections of this application are true and correct to the best of my knowledge. I approve the
application and agree that the results of any translational research funded will not be used for any commercial purposes and will be publicly
available with no limitations..
Name of Department
Type here
Head of Department
First name
Type here
Position held
Type here
Signature
Last name
Type here
Date
Type here
Last name
Type here
Date
Type here
Financial Authority
First name
Type here
Position held
Type here
Signature
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Host Institution:
The host institution agrees to act as host for the PhD candidate/post-doctoral fellow and to administer and account for the grant. The host
institution undertakes to support the project described in this application by making available accommodation, basic facilities for research, and
the services necessary for its fulfilment. We agree that the results of any translational research funded will not be used for any commercial
purposes and will be publicly available with no limitations..
Name of Host Institution
First name
Type here
Position held
Type here
Type here
Signature
Last name
Type here
Date
Type here
Any personal information in this application will be used only to assist with the administration and assessment of the application and any grant.
This information is restricted to the distribution committee considering this application, other parties that may need to be consulted, and officers
of, and people contracted to act on behalf of, the Department of Internal Affairs. Names and addresses of grant recipients will be published by the
Lottery Grants Board and may be released to the media or appear in publicity material. You are entitled to access the information and to amend it
if required. Other information may be released if requested under the Official Information Act. After 10 years this application may be transferred to
the National Archives where it will be available for public reference.
EMAILING YOUR APPLICATION
An application consists of:

a complete application form including a signed declaration.

If you are applying for a Post-Doctoral fellowship your CV and your academic transcript.

If you are applying for a PhD scholarship, your academic transcript.

written evidence of approval from the relevant research ethical committee for your region and discipline, if applicable. Where this approval is
not available at the time of the application, it should be forwarded to reach the Lottery Health Research Committee Coordinator as soon as
possible

a copy of the HSNO, GMO or Biosecurities approval, if applicable. Where this approval is not available at the time of the application, it should
be forwarded to reach the Lottery Health Research Committee Coordinator as soon as possible (See question B5)
Note: Grants cannot be uplifted until written evidence of approval by the relevant research ethical committee has been received.
Please email the completed application form and all necessary accompanying documentation in MS word or editable PDF format to
lhr@dia.govt.nz
Applications must be lodged in the lhr@dia.govt.nz mailbox by 4.00 pm on Wednesday 27 August 2014
Applications submitted after the closing date and time are unlikely to be accepted.
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Note A: Ethnic groups
Note B: Geographic areas
Main Ethnic Group
NZ European
Specific Categories
Pakeha/NZ European
Please select from the list below. You may enter as many regions and/or local
authority area(s) as appropriate. If your organisation is national in nature, please
select Nationwide.
Māori
Māori
Region
Local Authority Area(s)
Northland
Kaipara District
Far North District
Whangarei District
Auckland
Auckland
Waikato
Matamata-Piako District
Otorohanga District
South Waikato District
Thames-Coromandel District
Waikato District
Waipa District
Waitomo District
Franklin District
Hamilton City
Hauraki District
Rotorua District
Taupo District
Bay of Plenty
Tauranga District
Whakatane District
Western Bay of Plenty District
Taupo District
Kawerau District
Opotiki District
Rotorua District
Gisborne
Gisborne District
Hawkes Bay
Central Hawke’s Bay District
Hastings District
Napier City
Taranaki
New Plymouth District
Ruapehu District
South Taranaki District
Stratford District
Manawatu-Wanganui
Horowhenua District
Manawatu District
Palmerston North City
Rangitikei District
Ruapehu District
Stratford District
Tararua District
Taupo District
Wanganui District
Waitomo District
Wellington-Wairarapa
Carterton District
(Lower) Hutt City
Kapiti Coast District
Masterton District
South Wairarapa District
Upper Hutt City
Wellington City
Porirua City
Tararua District
Nelson-MarlboroughTasman
Marlborough District
Nelson City
Tasman District
West Coast
Buller District
Grey District
Westland District
West Coast
Buller District
Grey District
Westland District
Canterbury
Ashburton District
Banks Peninsula District
Christchurch City
Waimakariri District
Waimate District
Waitaki District
Chatham Islands
Chatham Islands District
Otago
Central Otago District
Clutha District
Dunedin City
Queenstown-Lakes District
Waitaki District
Southland
Gore District
Invercargill City
Southland District
Pacific
Asian
African
European
Cook Islander
Fijian (Note: Fijian Indian is listed under
Asian)
Niuean
Samoan
Tokelauan
Tongan
Tuvaluan/Ellice Islander
Other Pacific (e.g. Kiribati, Solomon Islands)
Various Pacific (3 or more Pacific ethnicities)
Bangladeshi
Chinese
Fijian Indian
Filipino
Indian
Indonesian
Japanese
Khmer/Kampuchean/Cambodian
Korean
Pakistani
Sri Lankan
Taiwanese Chinese
Vietnamese
Other Asian
Eritrean
Ethiopian
Somali
South African
Sudanese
Zimbabwean
Other African
Anglo-Celtic
Continental European
Other European
Latin American
Latin American
Middle Eastern
Afghani
Assyrian
Iraqi
Iranian/Persian
Kurd
Lebanese
Palestinian
Turkish
Other Middle Eastern
Rangitikei District
Taupo District
Wairoa District
Hurunui District
Kaikoura District
Mackenzie District
Selwyn District
Timaru District
Nationwide
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