RANZCOG FOUNDATION Research Scholarships, Travel Grants & Fellowships RESEARCH-BASED APPLICATION FORM
Closing Date for Applications: 30 June 2017
Please indicate from the below list ALL research-based scholarships, fellowships and grants for which you are eligible and wish to be considered:
Arthur Wilson Memorial Scholarship Fotheringham Research Scholarship Mary Elizabeth Courier Research Scholarship Norman Beischer Clinical Research Scholarship RANZCOG/OvCan Scholarship Robert Wrigley Pain Research Scholarship Taylor-Hammond Research Scholarship UGSA Research Scholarship RANZCOG NSW Regional Committee Trainee Research Grant RANZCOG NSW Regional Committee Fellow Research Grant
SECTION 1 – APPLICANT
Applicant Details Surname Given Names (in full)
Title Date of Birth
Address
Telephone (home) Telephone (work) Mobile Fax
Email Your association with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists
RANZCOG Foundation Research-Based Application Form 2017 Page 1 of 11 RANZCOG Trainee RANZCOG Fellow UGSA Member Other (please list)
Academic Qualifications
Undergraduate Degree / Diploma Institution Date of Award
Undergraduate Honours (if applicable)
Higher Degree (enrolled or completed) Institution Date of Enrolment/Award
Current Training Information (if applicable) Fellowship Training Program Institution Year of Training
Current Post and Appointments over the Past Two Years Current (Position, Hospital/Institution, Duration)
Previous (Position, Hospital/Institution, Duration)
RANZCOG Foundation Research-Based Application Form 2017 Page 2 of 11 Evidence of Esteem in Career RANZCOG Foundation scholarships, fellowships and grants aim to support the most promising early career researchers. Please provide any details of awards, recognition or esteem in your career so far. Award Institution / Awarding Body Date of Award
Previous Research Experience Please list the most significant research projects and activities with which you have been involved and what your involvement was.
Previous Research Output in Past Five (5) Years Please list your research publications and conference presentations (name and date) of the past five (5) years.
Track-Record in Relation to Opportunity The Research Grants Committee will consider the track-record of each applicant in relation to opportunity. Please provide below any additional information (such as leave or career break, other work, mentoring) relevant to your circumstances and research experience. Significance of Award for Career
RANZCOG Foundation Research-Based Application Form 2017 Page 3 of 11 Please outline the significance the scholarship/fellowship/grant would have for your career (500 words max).
SECTION 2 – PROJECT
Details of the Project Title
Field of research
Length1
Institution in which the project will be carried out (if more than one, indicate primary institution)
Institution Department Address
Supervisor Position Department Address
Project Aims and Hypotheses List the specific aims and potential significance of the project (hypotheses to be tested should be clearly stated)
Clinical Significance of the Proposed Project (maximum 500 words)
1 Applicants should refer to the Policy on Research Grant Assessment – Appendix B Duration of Planned Research, available on the RANZCOG Foundation website RANZCOG Foundation Research-Based Application Form 2017 Page 4 of 11 Background and Research Plan Please outline your research plan, limiting it only to that which will be supported by the RANZCOG Foundation scholarship. You may include up to a maximum of three pages for the Background and Research Plan.
RANZCOG Foundation Research-Based Application Form 2017 Page 5 of 11 Lay Description Briefly describe the research proposal in lay terms (maximum of 80 words, timeline should be stated).
Salary How will your salary be covered to enable you to pursue your research project?
Feasibility/Budget Please provide an indicative budget, listing the areas of anticipated expense(s). The information provided here will be considered by the Research Grants Committee in relation to the feasibility of the project. Completion of an acquittal form will be required on completion of the project.
Expense Description Amount ($)
Total Budget RANZCOG Foundation Research-Based Application Form 2017 Page 6 of 11 Delivery within Timeframe
Please justify the likelihood of completion of the project within the timeframe and budget, including timeline (500 words maximum).
Funding Applications Please indicate any other funding or grants awarded or which you intend to apply for in relation to this research.
Does this research project form part of a larger project for which a funding application, whether by yourself or others, been made? (e.g. NHMRC, APA, UPA) Please provide details.
Learning Opportunity and Contribution to the Project Please outline your actual involvement in the proposed study and what new skills you will acquire (500 words maximum).
RANZCOG Foundation Research-Based Application Form 2017 Page 7 of 11 Quality of Supervisory Support, Research Environment and Commitment to Training Please provide details of your supervisor and what experience in supervision he/she has and on the support your research environment will offer (500 words maximum).
Ethics Approval Grants are conditional on Ethics Committee approval and a letter from the relevant Ethics Committee confirming approval for the proposed project must be provided.
Ethics Committee Providing Approval for the Project:
Status of Approval: Approved (letter appended) Pending (please provide anticipated date of approval)
Please outline the ethical issue(s) associated with your research.
Endorsement of Supervisor The Research Grants Committee recognises the important role the research supervisor has in mentoring an early career researcher. Additional information is required from the research supervisor (Appendix A) and must be submitted with the application. Incomplete applications will not be considered by the Research Grants Committee.
RANZCOG Foundation Research-Based Application Form 2017 Page 8 of 11 Confirmation of Facilities and Infrastructure The Research Grants Committee requires an assurance that the institution/department in which the research is to be conducted has the necessary facilities and that appropriate support and infrastructure are in place.
As Head of Department, I confirm that the necessary infrastructure and support are in place for the conduct of the research to which this application relates, including the acceptance and management of the scholarship funds.
Head of Department Department Institution Signature of Head of Department Date
Declaration I declare that the information supplied by me is complete, true and correct in every particular.
Signature of Applicant
Date
Closing Date for Applications: 30 June 2017
Applications must be submitted to the RANZCOG Foundation via email to: [email protected]
Please note: Email submission of applications is required in both Word and PDF formats; please ensure that this page, with signatures, is submitted with your application.
RANZCOG Foundation Research-Based Application Form 2017 Page 9 of 11 Appendix A Research Supervisor Statement and Declaration
Details of the Project
Applicant Project Title Supervisor Position Department
Address
Supervisory Success The Research Supervisor plays an important role in mentoring an early career researcher. As such, consideration will be given by the Research Grants Committee to the record of supervisory success of the applicant’s Research Supervisor.
Please provide evidence of your success to date as a supervisor of early career researchers (maximum of 500 words).
Endorsement of Supervisor RANZCOG Foundation Research-Based Application Form 2017 Page 10 of 11 The supervisor/ mentor will also be required to approve the progress and final project reports (as appropriate) prior to submission to the Research Grants Committee.
As supervisor and mentor of this applicant, I confirm that this application has my support and that the planned research is feasible within the given timeframe, the scope and the aims of the project as set out in this application.
Supervisor/Mentor
Signature of Supervisor/Mentor
Date
Closing Date for Applications: 30 June 2017
Email submission of applications is required in both Word and PDF formats; please ensure that this page, with signatures, is submitted with your application.
RANZCOG Foundation Research-Based Application Form 2017 Page 11 of 11