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CIA Surname: Enter SurnameApplicationTITLE OF PROPOSAL Click here to enter project title.LAY SUMMARY (300 words maximum - to be used for promotional reporting as required)Click to enter lay summary.APPLICANT(S) Principal InvestigatorName (full):Click to enter Name.Position: Click to enter Position.Telephone: (work)Click to enter number.Telephone: (mobile)Click to enter mobile.Email:Click to enter email.Work Address:Click to enter address.Current Employer:Click to enter employer.Department:Click to enter dept.Australian Citizen or Permanent Residency:Yes ? No ? Click here to enter text.If you are applying as a Permanent Resident please provide your confirmation letter.Contribution to Project:Click to enter contribution Associate Investigator(s) if applicable (Copy and paste table if more required)Name:Click to enter AI NamePosition:Click to enter position.Current Employer:Click to enter employer.Department:Click to enter department.Telephone:Click to enter number.Email:Click to enter email Work Address:Click to enter address.Contribution to Project:Click to enter contribution Name:Click to enter AI NamePosition:Click to enter position.Current Employer:Click to enter employer.Department:Click to enter department.Telephone:Click to enter number.Email:Click to enter email Work Address:Click to enter address.Contribution to Project:Click to enter contribution Name:Click to enter AI NamePosition:Click to enter position.Current Employer:Click to enter employer.Department:Click to enter department.Telephone:Click to enter number.Email:Click to enter email Work Address:Click to enter address.Contribution to Project:Click to enter contribution PROJECT DETAILS Department Project being carried out: Click here to enter text.What part of the study is being conducted at the RAH (give details): Click here to enter text.Where else will this study be conducted? (Please tick those applicable)?SAHMRI?UNISA?University of Adelaide ?SA Pathology?Other: Click here to enter text.Hours per week on project (for each investigator): Click here to enter text.Who owns the project / protocol (Intellectual Property)? Click here to enter text.APPLICATION FOR OTHER RESEARCH SUPPORT CURRENTLY PENDINGList all other applications for this project noting; funding agency, project title, and funds requested. If there are no other applications for this project, please advise why this application is only being made for funds through the RAH Research Committee.Click here to enter text.CURRENT RESEARCH SUPPORTList current research support funding for each applicant giving the project title, value of support per annum and the source of funding.Click here to enter text.RELATIONSHIP OF THIS APPLICATION TO OTHER FUNDINGSpecify why existing support cannot be utilised to support the research proposed in this application Click here to enter PLIANCE APPROVALSEthics Approval required: Yes ? No ?Human ?or Animal ?Other: Click here to enter text.If No, please justify: Click here to enter text.Genetic Manipulation: Yes ? No ?Ethics application submitted (awaiting approval) ? CAHN Ref: Click here to enter text.Ethics to be submitted ? Date: enter a date.Project has existing ethics approval: ? If using existing/current ethics approvals, please provided confirmation from the relevant ethics committee that this new project proposal covered under the current HREC or AEC approval and attach the relevant approval letters.Ethics / Governance Reference Number (s): Approval letters Attached: Yes ? No ? N/A ? Q or R No.Click here to enter text. HREC Ref:Click here to enter text.SSA Ref:Click here to enter text.MYIP:Click here to enter text.STATEMENT ON ETHICAL CONSIDERATIONS (1/2 page maximum)Data and/or samples security and confidentiality:? Non-identifiable? Re-identifiable? IdentifiableClick here to enter text.CERTIFICATION (Attached as separate document) ? Letter attachedAll applications must have a signed letter of certification by the Department/Division Head that appropriate general facilities will be available to the investigator if successful and that the project will be carried out strictly in accordance with NHMRC Ethical and Scientific Practice Guidelines. Scientific ReviewersNominate a minimum of three external scientific reviewers who are competent to review this application. It is the responsibility of the applicant to obtain the consent of the nominated external reviewers. Please provide full contact details for each reviewer must be supplied. Referees must not be from the applicants department or associated with the project, nor have collaborated with the applicant(s) scientifically in the past five years.Full Name:Position:Phone:Email:1. 2. 3. research PROPOSALPURPOSE OF STUDY (1/2 page maximum)Click here to enter text.BUDGETCALHN Cost Centre funds to go into: Existing ? # Enter Oracle Project No. New ? Budget Details: Budget ItemDetailsProvide details of expenditureFunds/costs to:External Party eg. University, SAHMRI etc.AmountSalariesClick to enter text.$ $ Name: FORMTEXT ?????Employee No: Position No.: FORMTEXT ????? FORMTEXT ?????Classification: FTE: FORMTEXT ????? FORMTEXT ?????ConsumablesClick to enter text.$ $ EquipmentClick to enter text.$ $ OtherClick to enter text.$ $ TOTAL$ $ If funding is being used for salaries at CALHN please indicate if it is for a new employee or an existing CALHN employee. If it is for an existing employee, include in the details the employee’s name, current classification, and their employee number.JUSTIFICATION OF BUDGET (1/2 page maximum)Click here to enter text.AIMS (1/2 page maximum)Click here to enter text.BACKGROUND AND RESEARCH PLAN (3 pages maximum)Applicants are reminded this section should include a clear definition of study end points, statistical methods to be used, power calculations and an explanation of the relationship of the study to the applicants’ longer-term research agenda.Click here to enter text.REFERENCES (1 page maximum)Click here to enter text.ANALYSIS AND REPORTING OF RESULTS (1 page maximum)Click here to enter text.HOW WILL THIS PROJECT BENEFIT THE RAH? (300 Words)Click here to enter text.DATE OF PROPOSED COMMENCEMENT: Click here to enter a date.PREVIOUS RESEARCH ACTIVITY AND ACHIEVEMENTSCURRICULUM VITAE - Chief Investigator (not to exceed 3 pages)Click here to enter text.PREVIOUS RESEARCH SUPPORT (not exceeding one page)List research support funding for the Principal Investigator for the last four years giving the project title, value of support per annum and the source of funding. Click here to enter text.PUBLICATION HISTORY (list a maximum of 8 most relevant recent publications - no abstracts)Click here to enter text. ................
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