HRC-CDA Form s1

Form[Type text] HRC-CDA

HRC REF ID#

Career Development Award Application Form (HRC-CDA)

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 at their host organisation 4) create an account or use an existing one on the HRC online application website (https://secure.hrc.govt.nz/apply/index.php/home) 5) register this application on the website to get a HRC REF ID# for use on this form and all related correspondence 6) submit the application online by 12 noon on 3 July 2013 7) deliver hard copy to HRC by 5 July 2013 at 5 pm.

Enter the HRC Ref ID# in the box at the top left of this page. In the second page header, replace “nm/xyz” with your application HRC Ref ID#; replace “NI surname” with your surname.

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 Windows PC MAC

MODULE 1: APPLICANT Section 1A: General Information Applicant (also required for application registration online) Title First Name Middle Name(s) Surname

Email Address Department Host Organisation

Award applied for (tick one only) (also required for application registration online) Clinical Practitioner Research Fellowship Clinical Research Training Fellowship Foxley Fellowship Girdlers’ New Zealand HRC Fellowship Sir Charles Hercus Health Research Fellowship

Research Committee most suited to assess this application (tick one only) (also required for application registration online) Biomedical Research Committee Maori Health Committee Pacific Health Research Committee Public Health Research Committee

Research title (limit to 80 characters including spaces) (also required for application registration online)

Research Host Organisation Research Location

Total Amount Requested Start Date (dd/mm/yy) Completion Date (dd/mm/yy) Term Months

Institution and department enrolled at (if different from Research Host Organisation)

Qualifications to be completed during award* % Full time equivalent on course (%FTE) *

Keywords to describe your research

* If applicable

Application Summary (150 word limit) Include career and research objectives, principal methodologies and potential health outcomes (if applicable).

Delete these words and start typing here

Section 1B: Personal Information The personal information contained on this page may be made available to members of the HRC Committees relevant to the review of the application on a confidential basis. Some of the information may be used in a non-identifiable form for HRC statistical purposes.

Ethnicity Asian (specify) Māori/Iwi/Hapu New Zealand European Pacific (specify) Other (specify)

Applicant mailing address

Phone Mobile Email address

Are you a permanent New Zealand resident? Yes/No If “No”, what is your current visa status?

Employment Do you intend to be employed during the tenure Yes/No of this award1? If “Yes”, provide the following details: Place of employment Hours per week

Current employer (Foxley and Clinical Practitioner Research Fellowship applications only) Name Department (if applicable) Address

Phone Email Address Length of Service

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.

Section 1C: Career Plans (1 page) Briefly describe your background and potential; specifically, describe how the proposed award will support your career plans. All of the instructions in this section below can be deleted. Delete these words and start typing here. Applicants for the Clinical Practitioner Research Fellowship – Describe your clinical and research experience, how the proposed research aligns with your clinical practice, how it will strengthen healthcare practice and health services, and how the award will add to your institutional research environment.

Applicants for Girdlers’ New Zealand HRC Fellowship – Provide brief details about the New Zealand university department to which you plan to return, and the direction of your research to be undertaken once you have returned to New Zealand.

Section 1D: Academic Support Research Supervisor and/or other Investigators on this research (if applicable) Title, First name, Surname Role Institution/Organisation

Reasons for selection of supervisor/investigator

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Section 1E: Healthcare Organisation Support Clinical Practitioner Research Fellowship applicants only.

Research FTE Clinical FTE

Describe the support provided by your employer and the extent of clinical duties you will undertake during the term of this fellowship.

Section 1F: NZ Standard CV – Applicant Insert Standard CV here.The template can be downloaded from the HRC website with instructions. Ensure that details are identical to those listed in Module 1 to avoid delays in processing.

Ensure that all your publications are listed in full (with full authorship).

Delete all the instructions under the heading and paste standard CV here.

Section 1G: Applicant Academic Transcript (Not required for Clinical Practitioner Research Fellowship applications; provide evidence of postgraduate qualifications instead)

Provide a witnessed signed copy of your academic transcript and insert after this page.

Insert scanned document here

MODULE 2: RESEARCH INFORMATION Use the space below (8-page limit) to describe the research.

The research information should include: 1. A description of the applicant's previous and current research interests and work 2. A description of the proposed research, structured under the following headings.

Aims and objectives Delete these words and start typing here.

Timelines (use Gantt chart) Delete these words and start typing here.

Key milestones Delete these words and start typing here.

The Aims and Objectives, Timelines and Key Milestones will be used to form the basis of the contract if the application is successful.

Health significance Delete these words and start typing here.

Research design and methods Delete these words and start typing here.

Dissemination of results Delete these words and start typing here.

Sir Charles Hercus, Postdoctoral and Clinical Practitioner Research Fellowship applicants only. Potential for realising health and economic gains for New Zealand Delete these words and start typing here.

An indication of iwi and/or community support for the research (if relevant) Delete these words and start typing here.

MODULE 3: REFERENCES Use the one-page limit only (for Clinical Practitioner Research Fellowship applicants there is no page limit).

MODULE 4: CONTRACT INFORMATION AND BUDGET Use the HRC Excel Spreadsheets ‘HRC_CDAContractInfo.xls’ for Sections 4A – 4B.

For the hard copy of the application

Attach a printout of the spreadsheet Sections 4A-4B (Objectives and Milestone, FTE Summary) after this page of the application form.

Ensure any page breaks are logically placed to facilitate review.

For the electronic copy of the application

Upload the Excel file when submitting the application Word file to the online submission system (EASY). Use the required file name convention.

Section 4A – 4B

Section 4C – Contract Information Host Institution2 Has the Host Institution/Organisation committed to the financial support of this research?

Justification of Research Staff Explain and justify the role of personnel, who will be associated with your research, including any supervisors or investigators not funded through this research. These may be research assistants, technicians, medical staff, interviewers, support staff or similar, who have specific FTE involvements listed in Section 4B. Delete these words and start typing here.

Section 4D – 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 below the provided tables if additional tables are 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)

2 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.

If HRC contract (HRC Ref #), was Final Report filed? If not, why?

Delete these words and copy additional tables here if required. Section 4E – Other Support Other Research Applications Awaiting Decision Applicants must advise the HRC of the outcome of other research applications through their Research Office.

Copy and paste below the provided tables if additional tables are required.

Funding agency Title of research Investigators Start date and duration Total value Date of outcome Areas of overlap with this Application. HRC Ref #?

Delete these words and copy additional tables here if required. Co-Funding What other agencies or end-users have been approached or committed to joint or partial funding of this research?

Financial Interest(s) Do you or any named investigator have a financial interest related to the research or sponsorship of the research?

Yes No Financial interest?

If yes, outline below and provide details of your conflict management strategy.

Section 4F – Letters of Collaboration/Supporting Documents List List below all MOU or subcontracts and include copies with all copies of the application. All other documents should be paper-clipped separately with the original application only and should include the application HRC Reference ID#.

Letters of collaboration for this research which outline material or actual support can also be listed. Referees and Science Assessing Committee members will see the list below and documents will only be made available on request.

Delete all the instructions under the heading and start typing here.

MODULE 5: NZ STANDARD CV – Supervisor(s)/Investigator(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.

The template can be downloaded from the HRC website with instructions. Ensure that details are identical to those listed in Module 1 to avoid delays in processing.

Ensure that all your publications are listed in full (with full authorship).

Delete all the instructions under the heading and paste standard CVs here.

MODULE 6: ADMINISTRATION Do not copy any sections in MODULE 6. Send with original signed application only.

Section 6A – Host Institution/Organisation Salary Statement

Title, First names, Surname of applicant

Host Organisation Qualifications at time of application Title of award application Start date and duration Agreed salary3, $ Agreed grade

Declaration – I have read the attached application and on behalf of the institution named above, agree that the nominated salary is appropriate.

Signed (for Host Organisation)

Print name clearly

Position

3 Any salary variation after the approval process must be submitted in writing to the HRC and signed by both the applicant and the host institution.

Section 6B – Employer Statement (Foxley and Clinical Practitioner Research Fellowship applicants only)

Title, First names, Surname of applicant

Declaration – I am aware that the applicant is applying for an HRC Foxley Fellowship, which will require sabbatical from the normal work environment for 12 months. I support the application and will reinstate the applicant upon the conclusion of the award. or

Declaration – I am aware that the applicant is applying for an HRC Clinical Practitioner Research Fellowship, which will require the applicant to undertake research (0.3-0.5 full time equivalent) concurrently with clinical care or service delivery. I support the application.

Name of Organisation

Signed (for Organisation)

Print name clearly

Position

Section 6C – Ethical and Regulatory Agreement

Applicant

Research title

Yes No Ethics Committee Requires human ethical approval? Copy of current human ethical approval attached? Requires animal ethical approval? Copy of current animal ethical approval attached?

If this application does not require ethical approval, briefly provide reason.

If this application requires consent from other regulatory bodies such as ERMA, MAF, DOC, GTAC, SCOTT, Biosafety or Iwi, provide reason.

The applicant agrees to read the ‘Guidelines on Ethics in Health Research’ and ‘Te Ara Tika - Guidelines for Māori 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 has examined and agreed to the ethics required in association with 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.

Section 6D – Administrative Agreement This signed form must be returned to the HRC with the original copy of the contract application. Applications with an incomplete administrative agreement will not be processed. 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.

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. By signing this agreement we agree to ensure that all regulatory consents are gained as outlined in Section 6C – Ethical and Regulatory Agreement before any part of the research commences. 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%.

Applicant Name: Signed: Date:

Supervisor Name: Signed: Date:

Head of Department/School/Faculty or Hospital Name: Signed: Date:

Authorised official on behalf of Host Organisation Name: Signed: Date:

Position: Host name:

MODULE 7: AUSTRALIAN AND NEW ZEALAND STANDARD RESEARCH CLASSIFICATION (ANZSRC) Do not copy. Send with original application only.

This Module is for evaluation purposes and is mandatory; incomplete applications will not be processed.

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: REFEREE/SUPERVISOR NOMINATION Do not copy. Send with original application only.

Section 8A – Referee Nomination/Supervisor Report Sir Charles Hercus and Clinical Practitioner Research Fellowship applicants nominate impartial referees (not a person with potential conflicts of interest). Clinical Research Training Fellowship, Foxley and Girdlers applicants should ask their main supervisor to send the HRC a letter stating supervisory and resource arrangements.

Name Email address Area(s) of expertise Relationship to applicant (if any)

Name Email address Area(s) of expertise Relationship to

Section 8B – Potential Referees unacceptable to Applicant The HRC may seek further referees. You may exclude two potential referees if they are competitors or if you do not wish them to see your application.

Name Full address

Expertise Reason for exclusion

Name Full address

Expertise Reason for exclusion

Check List

 Be sure you have used the correct font size and have not exceeded page limits, since doing so may result in your proposal being returned and not

considered in this funding round.

Check the salary (if applicable) and the administration agreement sections to ensure all relevant signatures and attachments have been obtained.

Check to be sure you have included the confidential pages in your original application ONLY, and NOT in the copies submitted with the original.

Be sure that the ORIGINAL copy is PAPER-CLIPPED together, and that any PHOTOCOPIES are individually STAPLED.

A witnessed copy (not the original) of your academic record qualifications should be attached to the application.

Names of referees/supervisors provided (as applicable).

Additional documents can be inserted here (if applicable)