Form
HRC-PacificHMA
Form
PacificHMA
HRC REF #
Career Development Award Application Form (HRC-PacificHMA)
Applicants are advised to:
1) read the Guidelines for definitions and instructions before completing this form;
2) read the HRC Rules for applicant eligibility criteria and budgetary entitlements;
3) confirm the application due date for hardcopies and electronic files;
HRC Ref ID#:
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Applicant:
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This COVERSHEET is for identification purposes. It will be replaced by the online pages (Module
1, Section 1A) in the final submitted application compiled by the HRC Gateway
(https://gateway.hrc.govt.nz).
Information can only be entered into the fields indicated. Enter the details above before going to
page 2.
When completed, save this form as a pdf file before uploading to Gateway. In the pdf version of
this document, Section 1B must begin on page 2.
Due date for online submission is 12pm 2 September 2015. Hard copy delivered to HRC by 3
September 2015. Late applications will not be accepted. The information contained in this
application form must be full and correct, or it will be rejected.
Indicate type of computer used to complete this form (X): Windows PC:
or, MAC:
Enter the HRC Ref # in the box at the top left of this page.
In the second page header, replace “nm/xyz” with your application HRC Ref #; replace “NI
surname” with your surname.
HRC Ref ID#: nm/xyz
NI: NI Surname
MODULE 1: APPLICANT
Section 1B: Personal Information
Pacific affiliation/s
Applicant mailing address if different from your address for correspondence.
Phone
Mobile
Email address
Employment
Do you intend to be employed during the tenure
of this award1?
If “Yes”, please provide the following details:
Place of employment
Hours per week
Yes/No
Please note that if you are currently working and studying part time you may only receive part of the scholarship
Are you applying for a
Preventing and Minimising
Gambling Harm Career
Development Award?
Yes/No
Section 1C: Career Plans
Briefly describe your background and potential; specifically, describe how the proposed award
will support your career plans (1 page maximum)
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Section 1D: Academic Support
Research Supervisor(s)/academic support/cultural advisor(s)
Title, first name, surname
Role
Institution/Organisation
Reasons for selection of those listed above
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1
A recipient may not hold other paid positions without permission from the HRC Board. Normally this permission will be given for
teaching/clinical activities in support of the recipient’s professional development not exceeding 400 hours per year and with
approval from their supervisor.
HRC Ref ID#: nm/xyz
NI: NI Surname
Section 1E: NZ MSI Standard CV – Applicant
Expand tables as necessary by pressing enter at the end of a row outside of the table.
PART 1
1a. Personal details of Applicant
Full name
Title
First name
Second name(s)
Family name
Present position
Organisation/Employer
Contact Address
Postcode
Work telephone
Email
Personal website (if
applicable)
Mobile
1b. Academic qualifications
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1c. Professional positions held
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1d. Present research/professional speciality
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1e. Total years research experience
1f. Professional distinctions and memberships (including honours, prizes, scholarships, boards
or governance roles, etc)
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1g. Total number of peer reviewed
publications and patents
Journal
articles
Books, book
chapters, books
edited
Conference
proceedings
Patents
HRC Ref ID#: nm/xyz
NI: NI Surname
PART 2
2a. Research publications and dissemination history
Peer-reviewed journal articles
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Peer reviewed books, book chapters, books edited (SELECTED)
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Refereed conference proceedings
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Patents
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Other forms of dissemination (reports for clients, technical reports, popular press, etc)
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Please list any other awards/publications deemed relevant to your research (half a page
maximum).
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HRC Ref ID#: nm/xyz
NI: NI Surname
Section 1F: Applicant Academic Transcript
Please provide a witnessed signed copy of your academic transcript and insert after this page.
HRC Ref ID#: nm/xyz
NI: NI Surname
MODULE 2: RESEARCH INFORMATION
Overview of Proposed Research
Use the space below (8-page limit) to describe the research.
The research description should include:
1. A description of the applicant's field of research interest and an overview of research or
work previously undertaken by the applicant.
2. A summary of the proposed research, structured under the following headings:
Please note that the Aims and Objectives, Timelines and Key Milestones will be used to
form the basis of the contract if the application is successful.
The Preventing and Minimising Gambling Harm Scholarship is very specific in addressing the
prevention and minimisation of gambling harm, your proposal including the information under
following headings must reflect this. (see explanatory notes).
Aims and objectives
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Timelines (use Gantt chart)
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Key milestones
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Pacific Health significance
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Research design and methods
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HRC Ref ID#: nm/xyz
NI: NI Surname
Dissemination of results
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An indication of Pacific community and/or community support for the research (if relevant)
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MODULE 3: REFERENCES
Please use the one-page limit only
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MODULE 4: BUDGET AND CONTRACT INFORMATION
4A: Budget costs
Item
Fees
Stipend
Tufungatika Allowance
Cost
Section 4B – Contract Information
Host Institution2
Has the Host Institution/Organisation committed to support this research?
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The HRC expects that costs of the research undertaken by scholarship/fellowship recipients over and above that provided by the
award will be borne by the host institution. Applicants should confirm that such resources are in place to ensure the successful
completion of their award. Whilst it is the responsibility of the host institution to bear the cost of the research, this does not
preclude the submission of a proposal in the HRC funding round. Applicants should understand that such funding is contestable and
not guaranteed. The HRC’s contribution to research costs is intended to facilitate the establishment of the scholar/fellows research
programme.
2
HRC Ref ID#: nm/xyz
NI: NI Surname
Section 4C – Previous / Current Contracts and Awards
List Previous / Current Contracts awarded within the past 5 years. Final HRC reports may be
made available to Science Assessing Committees.
Copy and paste additional tables if required.
Funding agency
Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #),
was Final Report filed? If not,
why?
Funding agency
Title of research
Investigators
Start date and duration
Total value
Nature of support (1 sentence)
If HRC contract (HRC Ref #),
was Final Report filed? If not,
why?
Section 4D – Other Support
Other Research Applications Awaiting Decision
Applicants must advise the HRC of the outcome of other research applications through their
Research Office.
Please outline any other application awaiting decision
Funding agency
Total value
Date of outcome
Funding agency
Total value
Date of outcome
Section 4E – Letters of Collaboration/Supporting Documents List
Please identify agencies/communities etc that have provided any support letters to accompany
this application. (include all documentation with this application).
HRC Ref ID#: nm/xyz
NI: NI Surname
MODULE 5: NZ MSI STANDARD CV – Supervisor(s)
This information will be used to assess the suitability and expertise of your supervisor/research
team in the field of research you intend to undertake. Provide a CV for each individual if
applicable.
Expand tables as necessary by pressing enter at the end of a row outside of the table.
PART 1
1a. Personal details of Supervisor/Investigator
Full name
Title
First name
Second name(s)
Family name
Present position
Organisation/Employer
Contact Address
Postcode
Work telephone
Email
Personal website (if
applicable)
Mobile
1b. Academic qualifications
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1c. Professional positions held
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1d. Present research/professional speciality
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1e. Total years research experience
1f. Professional distinctions and memberships (including honours, prizes, scholarships, boards
or governance roles, etc)
Delete these words and start typing here.
1g. Total number of peer reviewed
publications and patents
Journal
articles
Books, book
chapters, books
edited
Conference
proceedings
Patents
HRC Ref ID#: nm/xyz
NI: NI Surname
PART 2
2a. Research publications and dissemination history
Peer-reviewed journal articles
Delete these words and start typing here.
Peer reviewed books, book chapters, books edited (SELECTED)
Delete these words and start typing here.
Refereed conference proceedings
Delete these words and start typing here.
Patents
Delete these words and start typing here.
Other forms of dissemination (reports for clients, technical reports, popular press, etc)
Delete these words and start typing here.
Please list any other awards/publications deemed relevant to your research (half a page
maximum).
Delete these words and start typing here.
HRC Ref ID#: nm/xyz
NI: NI Surname
MODULE 6: ADMINISTRATION
This Module will only be required from successful applicants offered a contract. It is provided
here for reference only. No signatures are required. The full administration agreement can be
downloaded from the HRC website.
Section 6A – Ethical and Regulatory Agreement
The applicant has read the ‘Guidelines on Ethics in Health Research’ and ‘Te Ara Tika Guidelines for Maori Research Ethics: A framework for researchers and ethics committee
members,’ available from the HRC website, and agrees to abide by the principles outlined in
them. The undersigned also agrees to provide written evidence before any research procedures
commence, that in any study involving animal or human subjects, animal or human materials or
personal information, a properly constituted accredited Ethics committee (a list of currently
accredited Ethics Committees is available on the HRC website) has examined and agreed to the
ethics of the proposal outlined in this proposal. If minor changes in the research design or
procedures have been required for ethical reasons, the HRC must be informed of them. The
undersigned also undertakes to ensure that all regulatory consents are gained before research
commences. For further information regarding the ethical approval process, please contact the
Secretary to the HRC Ethics Committee, ethics@hrc.govt.nz, or the appropriate accredited Ethics
Committee.
Section 6B – Administrative Agreement
All HRC applications must include an undertaking to abide by the following administrative
agreement:
1.
It is understood and agreed that this application and any contract awarded as a result of
this application is subject to the Health Research Council of New Zealand Rules
(“Permissible Use of Research Funding and Operation of Contracts”). Funds will not be
expended for any other purpose than described in this application.
2.
The host institution agrees and undertakes to bear all risk and claims connected with
any operation covered by this application and to indemnify and hold harmless the
Council against any and all liability suits, actions, demands, costs or fees on account of
death, injuries to persons or property, or any other losses resulting from or connected
with any act or omission performed in the course of the research.
3.
The host institution agrees and undertakes to support for the duration of any contract,
the work described in this application by making available accommodation, basic
facilities for research and the services necessary for its fulfilment.
4.
The Head of Department agrees to accept this research within his/her department if a
contract is made, agrees to provide workload relief for research staff working on this
contract (Principles of Full Cost Funding), and is aware that s/he may be requested by
the HRC to provide a confidential assessment of the research during the term of the
contract.
5.
The host institution official designated below agrees to ensure that the research will
have been approved, where necessary, by the appropriate institutional biosafety
committee and/or all other required regulatory agencies before research is commenced.
6.
The applicant(s) agrees to allow specified personal information to be used for statutory
and publicity purposes.
7.
The host institution has in place policies and processes to ensure that consultation with
Māori has occurred and the application is responsive to the needs and diversity of
Māori.
HRC Ref ID#: nm/xyz
NI: NI Surname
We the undersigned have read the above administrative agreement and undertake to abide by
the conditions of this agreement in respect of any contract made by the Health Research Council
of New Zealand as a result of this application. We the undersigned confirm that the information
provided in this application is to the best of our knowledge true, that all sections are correct at
the time of application submission, that each NI agrees to the stated FTE% contribution and that
funding to any NI from any source will not exceed 100 FTE%.
MODULE 7: AUSTRALIAN AND NEW ZEALAND STANDARD RESEARCH
CLASSIFICATION (ANZSRC)
This Module is for evaluation purposes and is mandatory; incomplete applications will not be
processed.
Do not copy MODULE 7. Send with original application only.
Applicants are required to categorise their research using the ANZSRC codes for Socioeconomic
Objective classifications found on the HRC web link (http://classifications.hrc.govt.nz) – find the
appropriate 6-digit code(s) and description and insert below. Only provide 3 categories with %
in increments of 10.
Research Descriptors
MSI Socioeconomic Objective (SEO) (6-digit code and description)
Weighting %
(increments of
10; totals to
100%)
MODULE 8: Supervisor Report and Unacceptable Reviewers
Section 8A – Supervisor Report
Name
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Email Address
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Area of Expertise
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Relationship to applicant
(if any)
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Section 8B – Potential Reviewers Unacceptable to Applicant
An individual or research group may be unacceptable as reviewers because: 1) they are direct
competitors, 2) there is a conflict of interest, 3) there are commercially sensitivity issues.
Name
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Organisation/Location
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Reason
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HRC Ref ID#: nm/xyz
NI: NI Surname
Name
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Organisation/Location
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Reason
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