HRC-CDA Form

HRC REF: NI: Surname

Career Development Award Application Form (Pacific CDA)

COVERSHEET

HRC Ref ID#: Click here to enter text.

Applicant: Click here to enter text.

Computer used to complete this form: Click here to enter PC or MAC

This COVERSHEET is for identification purposes. It will be replaced by the online pages (Module 1) in the final submitted application compiled by the HRC Gateway (https://gateway.hrc.govt.nz).

Information should only be entered into the fields indicated. Enter the details above before going to Section 1B.

MODULE 1: APPLICANT INFORMATION Section 1B: Personal Information

Details of Pacific indigenous descent

Indicate the type of scholarship/award you are applying for Pacific Health Summer Studentships Pacific Health Knowledge Translation Grant Pacific Health Research Masters Pacific Health Research PhD Pacific Clinical Research Training Fellowship Pacific Health Research Postdoctoral Fellowships Sir Thomas Davis Te Patu Kite Rangi Ariki Health Research Fellowship Pacific Health Research Preventing and Minimising Gambling Harm Awards See explanatory notes for descriptions

Will you be employed during your tenure? Yes/No Note: the HRC has an expectation that any award will be taken up on a full-time basis. Any alternative will be assessed on a case-by-case basis. Ensure, if this is the case, that sufficient justification is detailed below. If answered Yes, give details Place of Employment Hours per week Justification

Description of applicant’s field of interest Delete these words and start typing here

Overview of research/work previously undertaken by the applicant Delete these words and start typing here

Section 1C: Career Plans (1-page limit)

For all applicants, describe your background and potential; specifically, describe how the proposed award supports/relates to your career plans. Delete these words and start typing here

Section 1D: Academic and Organisation Support Provide details of research supervisor/s and / or other investigators on this research if applicable:

Delete these words and start typing here

CRTF applicants should include a letter from their main supervisor stating supervisory and resource arrangements under this section.

Research Supervisor(s) and/or other Investigators on this research (if applicable) Title, first name, surname Role Institution/Organisation

Reasons for selection of those listed above. Delete these words and start typing here

Section 1E: Applicant Academic Transcript

Provide a scan of witnessed signed copy of your academic transcript.

Section 1F: NZ Standard CV - Applicant

For Summer Studentships, please provide the CV of the supervisor/s instead. 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.

Click here to insert applicant CV. All other CVs can be uploaded separately. All details must be identical to elsewhere on this application. Follow CV Guidelines: no more than 2 pages for Part 1, 3 pages for Part 2. Arial 12-point font, standard margins, delete instructions. List publication with full authorship.

MODULE 2: RESEARCH INFORMATION Overview of Proposed Research Use the space below (8-page limit) to describe your research, structured under the headings below.

Note: 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

Aims and objectives Delete these words and start typing here

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

Research Design and Methods Delete these words and start typing here

Māori Health Advancement Delete these words and start typing here. How has Māori consultation informed your research design? How might your research contribute to the health needs of Māori? What is the health significance and context of this research to Māori? Discuss the incidence or prevalence in Māori, or indicate if not known to be significantly different from the general population. Have you sought advice for the study from a Māori researcher/representative?

Dissemination of Results Delete these words and start typing here. Include plans for stakeholder engagement and how research results will be communicated to ensure knowledge transfer and achieve change.

Potential for Realising Health and Economic Gains for New Zealand Postdoctoral and Davis Fellowship only Delete these words and start typing here

An indication of Pacific Community and/or Community Linkages and Support for the Research. Delete these words and start typing here

MODULE 3: REFERENCES (1-page limit)

Asterisks are to be placed beside applicants’ publications. Provide references in full and state full authorship (for example not Smith et al). Endnote lists must be copied into a plain text editor before pasting in here. Delete these words and start typing here

MODULE 4: BUDGET AND CONTRACT INFORMATION

Section 4A – Contract Information Host Institution1 Has the Host Institution/Organisation committed to the financial support of this research?

Complete information below (Postdoctoral and Sir Davis applicants only)

Full name Title First name Second name(s) Family name

Host Organisation Qualifications at time of application Title of award application Start date and duration Agreed salary2, $ Agreed grade

Outline costs associated with your study (Summer Studentship, Knowledge Translation Grant, MA applicants only)

Items Costs Fees Stipend (total) Tufungatika Allowance Other Total

Justification of Research Staff (Postdoctoral and Sir Davis applicants only) 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 4F.

Delete all the words below the heading and start typing here

1 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 Note: the salary amount must be the same amount reflected in the budget or the lesser total maybe taken. 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. HRC-Pacific CDA Form ©2017 Health Research Council of New Zealand. All rights reserved. Page 12 IN CONFIDENCE HRC REF: NI: Surname

Section 4B – Previous/Current Contracts and Awards List previous/current contracts awarded to applicant within the past 5 years.

Funding agency Title of research Investigators Start date and duration Total value Nature of support (one sentence) If HRC contract (HRC Ref #), was Final Report filed? If not, why?

Click here to paste in as many copies of the above table as required.

Section 4C – Other Support Other Research Applications Awaiting Decision Applicants must advise the HRC of the outcome of other research applications through their Research Office if known up to October 2017.

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

Click here to paste in as many copies of the above table as required.

Co-Funding What other agencies or end-users have been approached or committed to joint or partial funding of this research? Delete these words and start typing here

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

Delete these words and enter Yes or NO.

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

Section 4D – Letters of Collaboration/Supporting Documents List

List below all MOU or sub-contracts and include copies with the application. All other documents should be paper-clipped separately with the application and should include the HRC Reference ID#. Letters of collaboration, which outline material or actual support, can also be listed. Science Assessing Committee members will see the list below and documents will only be made available on request.

Section 4E - 4F Budget and FTE (PhD, Postdoctoral and Sir Davis applicants only) Upload the completed file for sections 4E-4F. The spreadsheet is available on the HRC website.