Moh Training and Research Scholarship Application

NRF – MOH HEALTHCARE RESEARCH SCHOLARSHIP (PhD) APPLICATION

1. Please read the instructions carefully and fill in all the sections. Indicate “N.A” if not applicable

2. Together with this application form, an application package should include the following supporting documents and letters. The checklist below is for your easy reference: Documents: Copy of Singapore National Registration Identity Card. Letters of appointment/employment contract and information on your latest remuneration package (e.g., salary, bonus, annual wage supplement). Details of Research Project under the following headings: Introduction, Aims, Hypotheses, Methodology and References. Information on optional/mandatory courses to be taken, if applicable. Document(s) detailing fee structure for PhD or Master’s training (if applicable). Declaration by OHR (ANNEX I). Letters from: CMB - Written commitment that the scholar will have a minimum of 30% protected time for research upon the scholar’s return from his/her training. HOD - Letter of recommendation that includes Department’s commitment to provide continuing oversight for the scholar’s training. Research Supervisor (during period of award) - Letter of undertaking and curriculum vitae (to include a record of research funding & a record of past and current fellows trained.) Research Mentor (after period of award) - Letter indicating commitment to mentor scholar upon scholar’s completion of the training award and curriculum vitae (to include a record of research funding & a record of past and current fellows trained.)

3. Please submit your application to:

National Medical Research Council 11 Biopolis Way, #09-10/11 Helios Singapore 138667 Fax: (65) 63243735

and a copy to:

The SAB Research Committee Secretariat Ministry of Health College of Medicine Building 16 College Road Singapore 169854 Fax: (65) 63259211 Please indicate the duration and locality of the proposed programme: Duration and Locality of programme Local Full-time Overseas Full-time

No. of months: No. of months: Location:

1. PERSONAL PARTICULARS Name of Applicant (as in NRIC) Surname: Given Name: Date of Birth: Place of Birth: Gender: Marital Status: (dd/mm/yyyy) Male Married Female Single

Nationality: NRIC No.: If Singaporean PR, please indicate date awarded PR status: (dd/mm/yyyy)

Home Address: Mailing Address:

Email Address:

Contact Numbers Home: Office: Hp: Fax: Qualifications (Academic & Professional)

Academic Grade:

Clinical Grade:

2. TRAINEESHIP INFORMATION Specialty Surgical Medical Others : _____

Year of Training BST Year AST Year Seamless Year 3. PROPOSED RESEARCH PROJECT (i) Research Project Title:

(ii) Key words:

Please provide a maximum of 6 key words related to the research project. (iii) Abstract: Between 200 to 300 words, please describe the aims, hypotheses, methodology and approach of the research proposal.

(iv) Detailed Research Proposal: Please also attach details of the research project, including:  Introduction  Aims  Hypotheses  Methodology The above should be in presented in no longer than 10 pages. References should be attached at the end of the proposal and does not count towards the page limit. Please present the research proposal on A4-sized paper, 1-inched margins, single-line spacing and size 12 Times New Roman font. (v) Field of Research / Health Category: Please select up to 5 categories from the following.

Blood Musculoskeletal Cancer Neurological Cardiovascular Oral and Gastrointestinal Congenital Disorders Renal and Urogenital Ear Reproductive Health and Childbirth Eye Respiratory Infection Skin Inflammatory and Immune System Stroke Injuries and Accidents Generic Health Relevance Metabolic and Endocrine Other : ______

A) PLACE OF RESEARCH TRAINING Department: Institution:

Address:

Duration of Research Training: ___ month(s)

Start Date: (dd/mm/yyyy) Completion Date: (dd/mm/yyyy) B) RESEARCH SUPERVISOR DURING AWARD Name: Email:

Designation: Phone:

Department: Institution: Field of Research / Health Category: [To indicate only if different from section 2(v)] Please select up to 5 categories from the following.

Please attach the following:  Letter of undertaking from the proposed Research Supervisor  CV [to include details of current and pending funding; i.e. name of agency, number of grants held, grant title, role (e.g. PI or co-PI), grant duration and the awarded budget]  Training record of the Research Supervisor (e.g., number of fellows previously trained and number of fellows currently in training) C) RESEARCH MENTOR (LOCAL) AFTER AWARD PERIOD Name: Email:

Designation: Phone:

Department: Institution:

Field of Research / Health Category: [To indicate only if different from section 2(v)] Please select up to 5 categories from the following.

Please attach the following:  Letter of undertaking from the proposed Research Mentor  CV [to include details of current and pending funding; i.e. name of agency, number of grants held, grant title, role (e.g. PI or co-PI), grant duration and the awarded budget]  Training record of the Research Mentor (e.g., number of fellows previously trained and number of fellows currently in training)

4. EMPLOYMENT INFORMATION OF APPLICANT Institution / Department:

Address of Employer:

A) HR CONTACT PERSON Name: Tel. No.:

Designation:

B) EMPLOYMENT HISTORY Date Institution / Appointment Department From To (dd/mm/yyyy) (dd/mm/yyyy)

(Please attach a letter of recommendation from Head of Department, your appointment letter/employment contract and information on your latest remuneration package.) 5. SCHOLARSHIPS/AWARDS

Date Scholarship/Award From To Funding Body (dd/mm/yy) (dd/mm/yy) 6. COURSE/SEMINARS/CONFERENCES ATTENDED IN THE LAST 3 YEARS

7. PUBLICATIONS BY APPLICANT 8. DECLARATION BY APPLICANT Please provide the following information:

Are you currently receiving any fellowship/training award? No Yes. Please specify:

Have you applied for funding from other agencies for the proposed training? No Yes. Please specify:

During the proposed training period, a) will you be accompanied by your spouse who is a recipient of an HMDP Fellowship or other training award? No Yes. Please provide the name of your spouse, training award and training period: b) will you be receiving any income from your current employer and/or any other hospital/institution in Singapore? No Yes. Please state the source(s) and the amount: c) will you be receiving any stipend from other source(s) (e.g., the institution where you will be training as a NMRC Fellow and/or any funding body outside Singapore)? No Yes. Please state the source(s) and the amount:

Please tick the items required for funding under the NRF-MOH Healthcare Research Scholarship: (Office of Human Resource to provide the estimated amount claimable in Annex I. Funding would be in accordance to Host Institution’s policy.) Salary Tuition fees

Maintenance allowance Insurance

Airfare(s) Conference(s)

Others (Please specify and justify):

I DECLARE that to the best of my knowledge the information I have provided on this form is true, accurate and complete.

I consent to the NMRC holding and using the data on this application form together with other documents attached for the purpose of administering and reviewing my scholarship application. I agree that such data may be made available to those who reasonably need to know within the NMRC and NMRC-appointed reviewers.

______Signature of Applicant ______Date (dd/mm/yyyy) 9. ENDORSEMENT BY HEAD OF DEPARTMENT

INSTITUTIONAL SUPPORT UPON THE COMPLETION OF TRAINING To be completed by HOD/Nominee. Please indicate the means by which the institution will support the returning scholar by ticking the appropriate box(es).

Please provide details Seed money for research grant (State the amount and source of seed funds) ______

Availability of lab space (Specify location of lab space and the area in ______square metres assigned to the scholar.)

Clinical position secured for the scholar for the first 3 years after his/her return. ______(Please specify.)

Salary support & protected time (should be aligned with the written commitment from CMB) ______as stated on Page 1, Point 2 of the application form.

Specify access to facilities & equipment ______

Technical manpower support ______

Collaboration opportunities ______(Name collaborators)

Others ______(Please specify.)

I support the above application for the NRF-MOH Healthcare Research Scholarship. The Institution will protect the scholar’s time, provide him/her with the necessary support, facilities and equipment as specified above upon completion of his/her PhD study to enable him/her development in clinical/biomedical research.

______Signature of Head of Dept Date

10. ENDORSEMENT BY THE INSTITUTION / MEDICAL SCHOOL

I support the above application for the NRF-MOH Healthcare Research Scholarship. The Institution will protect the scholar’s time, provide him/her the necessary support, facilities and equipment as specified in Section 9 upon completion of his/her PhD study to enable him/her development in clinical/biomedical research.

______Date Signature of Director/CEO of Institution

OR Dean of Medical School*

Name: * Please delete where appropriate ANNEX I: [FOR INSTITUTION HR’S USE ONLY] Breakdown of Fund Required for the NRF-MOH Healthcare Research Scholarship (Office of Human Resource to provide the estimated amount claimable in Annex I. Funding must be in accordance to Host Institution’s policy. Fund request should not be more than S$500,000 for local training and not more than S$800,000 for overseas training.)

Items Amt ($)

Salary (based on institution's certified payslips)

Maintenance allowance (PSC civil service rates)

Air Passage (PSC civil service rates)

Tuition fees

Insurance

Conference *

Others (please specify)

Funding estimate provided by:

______Signature of HR Officer

Name: Designation: Date: (dd/mm/yyyy)

* Up to $4k a year; airfare (economy class); airport transfer (i.e. taxi fare between airport & trainee’s residence, taxi fare between airport & conference venue); registration fees; accommodation (subjected to host institution’s guidelines).