Office Use Only – Application Ref SPARC/04/17/
NIHR Infrastructure Short Placement Award for Research Collaboration (SPARC) Application Form
Applicant Name:
Contact Tel:
Email:
Published October 2017 Page 1 of 9 SECTION A – APPLICATION SUMMARY
Ai. Trainee Details
Surname Forename Title ******
Job title
Qualification *****
Professional background please select from drop down lists *****
Medical Specialties: A – F *****
Medical Specialties: G – N *****
Medical Specialties: O – V *****
Other (Medically qualified) ***** if other please specify
Dental Specialties ***** if other please specify 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
Placement Title
Proposed start date ******
Aii Home Institution Details Applicant’s Department
Applicant’s Institution
Applicant’s Address
Published October 2017 Page 2 of 9 Applicant’s Postcode
Primary Supervisor - name
Primary Supervisor - contact phone number
Primary Supervisor – email address
Applicant contact details for correspondence (if different from above)
Address
Postcode
Phone no
SECTION B – TRAINEE EXPERIENCE
Overview of experience to date (150 words max)
Published October 2017 Page 3 of 9 SECTION C – PLACEMENT HOST INSTITUTION AND SUPERVISOR
Contact details
Surname Forename Title ******
Job title
Address 1
Address 2 Phone No
Address 3 email
Town/City
Address 5
Postcode
Published October 2017 Page 4 of 9 SECTION D – PROPOSED PLACEMENT TRAINING PROGRAMME
Di. Please outline the plan for your placement, and describe how it will contribute to your research training (250 words max)
Dii. Please outline the benefits and potential impact of the placement for your research and training (150 words max)
Published October 2017 Page 5 of 9 Diii. Please provide details of the host supervisor and how they will support the applicant (150 words max)
Div. Please justify the resources requested for the placement (up to £5000)
Published October 2017 Page 6 of 9
SECTION 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 undertake to conduct the research according to such guidelines for good research practice as the Host Institution 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 NIHR Infrastructure SPARC award.
I understand that the application will be shared with members of the Expert Review Panel and may be sent for external peer review.
Published October 2017 Page 7 of 9 Name (please print) Signature Date (dd/mm/yyyy)
Home Institution – Primary Supervisor
As Primary Supervisor of the Applicant at the home institution, I approve this application and will support the candidate’s pro gramme of activities as detailed in this application. The applicant is eligible for and capable of taking up this award. I confirm t hat 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)
Host Institution – Supervisor
As host institution 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:
Signature:
Date:(dd/mm/yy)
SECTION F – NIHR INFRASTRUCTURE HOME TRAINING LEAD STATEMENT OF SUPPORT
Published October 2017 Page 8 of 9 I agree that the candidate will benefit from the placement given that they meet the objectives described in the plan above. The opportunity will complement the research training he/she is currently undertaking. There is also the potential of publications and other communications on the outcomes of this work that will add value to all the involved institutions and to the NIHR as a whole. This placement will also benefit the institutions by establishing further links and potentially lead to other collaborations on research programmes.
I recommend and support this application for a placement to the decision-making panel at the NIHR. By signing below, I certify that I have read and agree with the above statement. I have also read and understood the guidance notes.
Name
Email address
Signature
Date:(dd/mm/yy)
SECTION G – 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
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Published October 2017 Page 9 of 9