1 - Health and Social Care in Northern Ireland



| |

| |PLEASE COMPLETE IN TYPESCRIPT. | |

| |COMPLETED APPLICATIONS MUST BE SIGNED AND RETURNED BY | |

| |2.00pm Wednesday 16th September 2015 | |

| |

|1a. |FULL TITLE OF KNOWLEDGE EXCHANGE PROJECT |

| | | |

| | |

|1b. |CHIEF INVESTIGATOR’S DETAILS |

| |Name (inc. title) |Job Title |Employing Organisation | |

| | | | | |

| |

|1c. |CORRESPONDANCE DETAILS (Chief Investigator) |

| |

| |Department | | |

| |Address | | |

| | | | |

| |Postcode | | |

| |

| |Telephone (work) |

| |Mobile |No. | | |

| | |

| |E-mail | | |

| |

|1d. |CO-INVESTIGATOR’S DETAILS |

| |Name (inc. title) |Job Title |Employing Organisation | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| |

| |Please provide a current CV for the Chief Investigator and all Co-Investigators using Appendix 1 | |

| |

|2. |PROPOSAL SUMMARY |

| |Public / lay title of Knowledge | | |

| |Exchange Project | | |

| |

| |

| |Total Funding Requested from HSC R&D |£ |(limit £100,000) |

| |Division | | |

| |

| |

| |Summary of your project in plain English. | |

| |(Include: the ‘problem/need’; the knowledge exchange objective(s); and the likely impact of the project) | |

| | | |

| |use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes | |

|3. |UNDERPINNING RESEARCH |

| |Tell us about the research which underpins this knowledge exchange. Summarise the key findings from this research with reference to the |

| |most relevant research outputs. |

| | | |

| |use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes | |

|4. |KNOWLEDGE EXCHANGE PLAN (page 1 of 3) |

| |Include the problem/need, the proposed solution, the methodology (inc. the theoretical foundations for research implementation), the | |

| |expected impact, the evaluation plan and the timetable. | |

| | | |

| |use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes | |

NB. Text will not automatically spill over onto the next page. Ensure that each page is completed separately

|4. |KNOWLEDGE EXCHANGE PLAN (page 2 of 3) |

| | | |

| | | |

| |use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes | |

NB. Text will not automatically spill over onto the next page. Ensure that each page is completed separately

|4. |KNOWLEDGE EXCHANGE PLAN (page 3 of 3) |

| | | |

| | | |

| |use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes | |

NB. Text will not automatically spill over onto the next page. Ensure that each page is completed separately

|4. |REFERENCES (page 1 of 1) |

| | | |

| | | |

| |use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes | |

---Please duplicate this page if you need to add additional space for references---

|5. |DELIVERY OF KNOWLEDGE EXCHANGE |

| |Include detail on: the role of the knowledge exchange team in generating the underpinning research; the team’s experience in knowledge |

| |exchange/management; how/what each member contributes to the project; and any wider engagement included in the programme. |

| | | |

|use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes |

|6. |SUSTAINABILITY AND FUTURE IMPLEMENTATION |

| |Describe how the knowledge exchange will be sustained and/or any potential issues that might affect wider implementation. Comment on how |

| |the project aligns with HSC strategy or commissioning priorities. |

| | | |

| |use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes | |

|7. |PERSONAL AND PUBLIC INVOLVEMENT |

| |Describe how service users and the public, including from appropriate groups, have been involved in identifying the knowledge exchange| |

| |topic and/or in preparing this application. | |

| | | |

| |Describe how service users and the public will be involved as partners in the proposed knowledge exchange project. Highlight the | |

| |benefits of this involvement. Justify the level of/approach to this involvement. | |

| | | |

| |Describe how you aim to incorporate PPI in the reporting/dissemination of the project. | |

| | | |

|use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes |

|8. |FINANCE SUMMARY |

| |Provide a summary of the overall cost by organisation. Detailed costing will be required at the full application stage. All organisations|

| |listed under the co-investigators must be included here. If there are no associated costs with a particular organisation please list them |

| |here with zero cost. |

| |Host Organisation |Description of costs |Total (£) | |

|1 | | | | |

| |Other Organisations |Description of costs |Total (£) | |

|2 | | | | |

|3 | | | | |

|4 | | | | |

|5 | | | | |

|6 | | | | |

| |Total | | |

| | |

|9. |FINANCE – JUSTIFICATION FOR SUPPORT |

| |Provide detailed justification for the costs identified in Section 8. Include justification of any organisations involved but where there |

| |are no associated costs. |

| | | |

|use Arial font size 11pt & single line spacing, adhere to any word limits, do not extend existing text entry boxes |

|10. |DECLARATIONS |

| |

|APPLICANT (CHIEF INVESTIGATOR) |

| |“I declare that the information on this application form and any other information given in support of this application is correct to | |

| |the best of my belief. I declare that all the signatures (original or electronic) contained within this applicant are valid and have | |

| |full approval” | |

| |

|Full Name | | |

| |

|Original Signature | |Date | | |

| |

|HOST ORGANISATION |

| |“As Designated Officer (e.g. Head of Department, Director of Research, CEO, Research Office Manager) I approve the details contained in | |

| |this outline proposal. I confirm that I have read the application and that, if awarded, the work will be accommodated in the named Host | |

| |Organisation, the applicant will be supported and the terms & conditions of the award upheld.” | |

| |

|Full Name | | |

| |

|Position | | |

| |

|Organisation Name | | |

| |

|Original Signature | |Date | | |

| |

| |Please return completed application and copies to: | |

| | | |

| |HSC Knowledge Exchange Scheme | |

| |HSC R&D Division | |

| |Public Health Agency | |

| |12-22 Linenhall Street | |

| |BELFAST | |

| |BT2 8BS | |

| |

| |CHECK LIST Please ensure you have enclosed the following: |

| | |One signed original application |

| | |

| | |One copy of the current CV for each member of the Knowledge Exchange Team |

| | |

| |

Appendix 1

CURRICULUM VITAE OF APPLICANT (a CV must be included for each applicant. CVs must be completed using Arial font size 11 or greater and must not exceed 3 pages)

|1. Surname |Forename(s) |

| | |

|2. Degree, etc |Degree |Class |University |Date |

|Subject | | | | |

|3. Current post held (please identify tenure and source of funding) |

|4. Previous posts held (with dates) |

|5. Recent publications (including papers in press) |

|6. Recent grants awarded (including your role (Chief-Investigator, Co-Investigator etc.), awarding body, dates of tenure, grant total and |

|proportion awarded to you) |

-----------------------

HSC Research and Development

2015 Knowledge Exchange Scheme

“Improving the Impact of Research”

Outline Application Form

June 2015

(Version 1.1)

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download