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Research Support Scheme2018 Application for Early Career Research Fellowships (Post-Doctoral)The Early Career Research Fellowships provide funding to foster career development in clinical research for medical personnel who have completed a PhD, or nursing and allied health personnel who have completed a PhD, and relevant qualifications have been completed within the past four years. The recipient works under the mentorship of a Senior Clinician within MSH. ECRFs provide flexible support from 0.2 to 1.0 FTE for up to 3 years. Up to two (2) ECRFs may be available: 1 x Medical ECRF: provides salary support up to $121,000 / annum (full-time, pre-tax) + $5,000 / annum for research-related expenses and consumables. Part-time awards are adjusted pro-rata.1 x Allied Health & Nursing: $97,000 / annum (full-time, pre-tax) + $5,000 / annum for research-related expenses. Part-time awards are adjusted pro-rata. Application InstructionsRefer to the 2018 Funding Guidelines when preparing your application. All sections of the form must be completed. The Applicant is required to sign the application on behalf of the research team. SubmissionApplications must be submitted electronically to CHR-RSS@health..au:A signed copy of the application to be submitted as a PDF,The application must also be submitted in Word format (signatures not required).Files must not exceed 2 MB in size and should be named using the following naming convention:Applicant Surname_2018 Funding TypeE.g., Smith_2018 Early CareerElectronic Applications must be received by the Centres for Health Research no later than 9.00 am (aedt), Monday 21st August, 2017Late or incomplete applications may not be acceptedEnquiries regarding the Research Support Scheme should be directed to:Centres for Health Research, Metro South Health Email: CHR-RSS@health..au Phone: 07-34438057Applicant Eligibility ChecklistTo be eligible for a 2018 Early Career Fellowship the Applicant must be able to answer:Medical Applicants must answer Yes to questions 1 (i,ii,and iii)Nursing and Allied Health Applicants must answer Yes to questions 2 (i,ii,and iii)All Applicants must answer YES to questions 3 to 7 X All Applicants must answer NO to question 8YesNo1Medical Applicants: Have you completed a Doctorate of Philosophy (PhD)? Do you have a MBBS or equivalent?Did you complete your MBBS or PhD in the last 4 years? (unless career disruptions exist- please see section 6.2.1 of the NHMRC funding rules)Note: Applicants may have completed MBBS and PhD in any order. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 2Nursing and Allied Health Applicants: Have you completed a Doctorate of Philosophy (PhD)? Are you a certified Allied Health worker or Nurse?Did you complete your training or PhD in the last 4 years? (unless career disruptions exist- please see section 6.2.1 of the NHMRC funding rules)Note: Applicants may have completed Nursing/Allied Health and PhD in any order. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX 3Are you a member of staff at PAH or a MSH Hospital (or have a formal appointment with MSH)? FORMCHECKBOX FORMCHECKBOX 6Will your MSH appointment be at least 0.5 FTE for the duration of the grant? FORMCHECKBOX FORMCHECKBOX 4Does your mentor hold an MSH appointment greater than or equal to 0.5 FTE? FORMCHECKBOX FORMCHECKBOX 5Will your research be undertaken in a clinical unit within MSH? FORMCHECKBOX FORMCHECKBOX 7Will the majority (more than 50%) of the research activity take place on a MSH campus? FORMCHECKBOX FORMCHECKBOX 8Is the proposed research activity currently funded through an award type currently listed on the Australian Competitive Grants Register or international equivalent? FORMCHECKBOX FORMCHECKBOX Applicant Appointment DetailsProvide details of the Researcher’s and Primary Mentor/Supervisor’s MSH and/or academic partner university appointment(s) (maximum 300 characters including spaces)E.g.: Occupational Therapist/CN/Staff Specialist at PA Hospital; MSH provides 50% of my salary; .NOTE: N/A (or similar) will not be acceptedResearcher / Applicant FORMTEXT ?????Primary Mentor FORMTEXT ?????Location of research activityProvide details of where the majority (more than 50%) of the research activity will take place (maximum 300 characters including spaces) FORMTEXT ????? Other Submitted Grant ApplicationsProvide details of grant applications related to this study submitted to other funding bodies in the current yearFunding body and typeProject titleBudget FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????Research Support Scheme2018 Early Career RESEARCH Fellowship (Post-Doctoral) ApplicationResearch Support Application Type (select one) Medical FORMCHECKBOX Nursing / Allied Health FORMCHECKBOX Project Title(Maximum 200 characters including spaces) FORMTEXT ?????Investigative teamThe Applicant must be the PI (Principal Investigator); The CI1 must be the mentor / supervisor;The maximum number of: Co-Investigators (CIs) = 4; Associate Investigators (AIs) = 2TitleNameHealth professionOrganisationPI FORMDROPDOWN FORMTEXT First name FORMTEXT Surname FORMDROPDOWN FORMDROPDOWN CI1 FORMDROPDOWN FORMTEXT First name FORMTEXT Surname FORMDROPDOWN FORMDROPDOWN CI2 FORMDROPDOWN FORMTEXT First name FORMTEXT Surname FORMDROPDOWN FORMDROPDOWN CI3 FORMDROPDOWN FORMTEXT First name FORMTEXT Surname FORMDROPDOWN FORMDROPDOWN CI4 FORMDROPDOWN FORMTEXT First name FORMTEXT Surname FORMDROPDOWN FORMDROPDOWN AI1 FORMDROPDOWN FORMTEXT First name FORMTEXT Surname FORMDROPDOWN FORMTEXT Type name hereAI2 FORMDROPDOWN FORMTEXT First name FORMTEXT Surname FORMDROPDOWN FORMTEXT Type name hereAssessment of Early Career Fellowship applications will be against the criteria LISTED BELOW:Assessment Criteria 1: Scientific Quality Assessment Criteria 2: Clinical SignificanceAssessment Criteria 3: Originality and InnovationAssessment Criteria 4: Track Record - Relative to OpportunityAssessment Criteria 5: Collaborative Strength Assessment Criteria 1: Scientific quality (20%)3.1.1Research Proposal Provide your research proposal on the following pages. Include Applicant’s name, Title of project; Hypothesis; Expected outcomes, Background, Research protocol and references.Assessment of the scientific quality of the research will be based on: Definition of project (based on clear articulation of the Hypothesis, Background, Expected outcomes)Study Design (Based on Methods, Research Protocol)Feasibility (including assessment of Methods and Budget);Whether the proposal would be competitive nationally. Insert your Research Proposal in the box below (You can type directly into the box; cut and paste or insert an embedded PDF. See Instructions – inserting text)InstructionsResearch Proposal FormatMaximum 4 pages including referencesArial font with a minimum size of 10 point (including tables, table legends and figure legends)Line spacing of 1.5 linesTop and bottom page margins of 2 cmLeft and right page margins of 2 cmDO NOT alter headers or footers.Inserting TextType directly into the text box above, maintaining format as described above; orCut and paste (e.g. from a previous document) into the text box – note you may lose formatting if you choose this option; orEmbed a PDF document of your complete proposal, maintaining formatting as described below.Prepare your Research Proposal as per the format instructions above Save your Research Proposal as a PDF documentPlace Cursor in the box aboveSelect “Insert” tab on MSWord ToolbarSelect “Object” and choose “Create from File” from drop downBrowse for your PDF documentSelect InsertSelect “Display as Icon”Click OKAn icon of your Research Proposal content should be displayed in the box above. You may remove the text box border for all options.3.1.2 BudgetItemDescriptionAmountPersonnel/Salaries FORMTEXT ?????$ FORMTEXT ?????Maintenance(consumable items to be purchased) FORMTEXT ?????$ FORMTEXT ?????Equipment FORMTEXT ?????$ FORMTEXT ?????Other(NOTE: computers will not be funded) FORMTEXT ?????$ FORMTEXT ?????Total$ FORMTEXT ?????Budget justification(maximum 1,000 characters including spaces) FORMTEXT ?????3.2Assessment Criteria 2: CLINICAL SIGNIFICANCE (20%)Assessment of the significance of the proposed research will be on the basis of: Burden of disease;Translation Impact;Innovation.3.2.1Burden of diseaseDescribe how this project will address and reduce the burden of disease addressed in your proposal (maximum 750 characters including spaces) FORMTEXT ?????3.2.2 Translational Aspect of the Research ProposalWhat is the translational aspect of your project? (Please indicate in boxes to the left) FORMCHECKBOX T0 – Identification of opportunities and approaches to a health problem (basic research) FORMCHECKBOX T1 – Findings from basic research tested for clinical effect and/or applicability (Phase I and II clinical trials; observational studies) FORMCHECKBOX T2 – Health application to evidence based practice guidelines (Phase III clinical trials; observational studies; evidence synthesis and guidelines development) FORMCHECKBOX T3 – Practice guidelines to health practices (dissemination research; implementation research; diffusion research; Phase IV clinical trials) FORMCHECKBOX T4 – Practice to population health (outcomes research; population monitoring of morbidity, mortality, benefits and risk studies) FORMCHECKBOX Not applicableDefinitions taken from UC San Diego Clinical and Translational Research Institute3.2.3 research significance Why is this research clinically significant? (Maximum of 750 characters including spaces) FORMTEXT ?????3.3 Assessment Criteria 3: CLINICAL Originality and Innovation (20%)Describe how your proposal is clinically original and / or innovative ? (maximum of 750 characters including spaces) FORMTEXT ?????3.4 ASSESSMENT CRITERIA 4: TRACK RECORD (20%)3.4.1early career FELLOWship applicantECF Contact DetailsApplicant name FORMDROPDOWN FORMTEXT First Name FORMTEXT SurnamePosition FORMTEXT ?????Organisational department FORMTEXT Department namePhone number(s)Primary: FORMTEXT ?????Secondary: FORMTEXT ?????Email address FORMTEXT ?????Postal address FORMTEXT Address line 1 FORMTEXT Address line 2 FORMTEXT Address line 3 FORMTEXT Suburb and PostcodeECF ACADEMIC Qualifications & APPOINTMENTS Academic QualificationsEg: MBBS: FORMTEXT ?????Academic AppointmentsEg: Senior Lecturer, XXDept, UQ : FORMTEXT ?????Research TimeExpected 2018 time allocation to:This study (hr/wk): FORMTEXT ?????Other studies (hr/wk): FORMTEXT ?????Do you expect to have an extended period of absence during 2018?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, provide expected dates FORMTEXT DD/MM/YEAR - FORMTEXT DD/MM/YEARReason(300 characters including spaces) FORMTEXT ?????PublicationsList publications produced in the last 5 years which have the most relevance to the study proposed in this application with ALL authors provided Press <Enter> after each publication to maintain the numbering system FORMTEXT ?????Conference presentationsList research conference presentations you have delivered (maximum of 10)Presentation typePresentation titleConference nameLocationDate(s) FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Awards and PrizesList your six most significant awards or prizes obtainedAwarding bodyTitleTypeYear FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ???? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????GrantsProvide details of research funding received in the last 5 years and indicate whether the funding relates to the proposed research of this application. If more than8 – please eliminate least applicable to this research proposal.Funding body and typeStart dateEnd dateAmountRelevant to this application? FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX Peer review involvementList your involvement in peer review. Involvement may include (but is not limited to) committees, grant review, review of publicationsPress <Enter> after each entry to maintain list formatting FORMTEXT ?????resEarch performance relevant to OpportunityAre there any disruptions to your career (greater than 28 calendar days) that may have impacted on your research performance that you would like to have taken into consideration? For example: Pregnancy; Major Illness or injury; Carer responsibilities.Please outline in the section below in 300 characters or less. FORMTEXT ?????3.5 ASSESSMENT CRITERIA 5: Collaborative strength (20%)3.5.1PRIMARY SUPERVISOR (Ps1)PS1 Contact DetailsPS1 name FORMDROPDOWN FORMTEXT First Name FORMTEXT SurnamePosition FORMTEXT ?????MSH site FORMDROPDOWN Organisational department FORMTEXT Department namePhone number FORMTEXT ?????Email address FORMTEXT ?????PS1 ACADEMIC Qualifications & APPOINTMENTS Academic QualificationsEg: MBBS: FORMTEXT ?????Academic AppointmentsEg: Senior Lecturer, XXDept, UQ : FORMTEXT ?????PS1 Research TimeExpected 2018 time allocation to:This study (hr/wk): FORMTEXT ?????Other studies (hr/wk): FORMTEXT ?????Do you expect to have an extended period of absence during 2018?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, provide expected dates FORMTEXT DD/MM/YEAR - FORMTEXT DD/MM/YEARReason(300 characters including spaces) FORMTEXT ?????PS1 PublicationsList your publications produced in the last 5 years which have the most relevance to the study proposed in this application with ALL authors provided) Press <Enter> after each publication to maintain the numbering system FORMTEXT ?????PSI GrantsProvide details of research funding received in the last 5 years and indicate whether the funding relates to the proposed research of this application. If more than 8 – please eliminate least applicable to this research proposal.Funding body and typeStart dateEnd dateAmountRelevant to this application? FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? FORMTEXT [DD/MM/YYYY] FORMTEXT [DD/MM/YYYY]$ FORMTEXT ?????Yes FORMCHECKBOX No FORMCHECKBOX 3.5.2Co-Investigator 1 (CS1)CI1 Contact DetailsCI1 name FORMDROPDOWN FORMTEXT First Name FORMTEXT SurnamePosition FORMTEXT ?????MSH site FORMDROPDOWN Organisational department FORMTEXT Department namePhone number FORMTEXT ?????Email address FORMTEXT ?????CI1 ACADEMIC Qualifications & APPOINTMENTS Academic QualificationsEg: MBBS: FORMTEXT ?????Academic AppointmentsEg: Senior Lecturer, XXDept, UQ : FORMTEXT ?????CI1 ParticipationSummarise the role of CI1 in the broad research plan proposed in this application (maximum 300 characters including spaces) FORMTEXT ?????CI1 Research TimeExpected 2018 time allocation to:This study (hr/wk): FORMTEXT ?????Other studies (hr/wk): FORMTEXT ?????Does CI1 expect to have an extended period of absence during 2018?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, provide expected dates FORMTEXT DD/MM/YEAR - FORMTEXT DD/MM/YEARReason(300 characters including spaces) FORMTEXT ?????CI1 PublicationsList publications produced in the last 5 years with ALL authors providedIndicate publications relevant to this application with an asterisk (*)Press <Enter> after each publication to maintain the numbering system FORMTEXT ?????3.5.3. Co-Investigator 2 (CI2)ci2 Contact DetailsCI2 name FORMDROPDOWN FORMTEXT First Name FORMTEXT SurnamePosition FORMTEXT ?????MSH site FORMDROPDOWN Organisational department FORMTEXT Department namePhone number FORMTEXT ?????Email address FORMTEXT ?????CI2 ACADEMIC Qualifications & APPOINTMENTS Academic QualificationsEg: MBBS: FORMTEXT ?????Academic AppointmentsEg: Senior Lecturer, XXDept, UQ : FORMTEXT ?????CI2 ParticipationSummarise the role of CI2 in the broad research plan proposed in this application (maximum 300 characters including spaces) FORMTEXT ?????CI2 Research TimeExpected 2018 time allocation to:This study (hr/wk): FORMTEXT ?????Other studies (hr/wk): FORMTEXT ?????Does CI2 expect to have an extended period of absence during 2018?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, provide expected dates FORMTEXT DD/MM/YEAR - FORMTEXT DD/MM/YEARReason(300 characters including spaces) FORMTEXT ?????CI2 PublicationsList publications produced in the last 5 years with ALL authors providedIndicate publications relevant to this application with an asterisk (*)Press <Enter> after each publication to maintain the numbering system FORMTEXT ?????3.5.4 Associate InvestigatorsAssociate Investigator 1Outline the role of AI1 in the broad research plan proposed in this application and indicate why AI1 has been included within the research team (maximum 1,000 characters including spaces) FORMTEXT ?????Associate Investigator 2Outline the role of AI2 in the broad research plan proposed in this application and indicate why AI2 has been included within the research team (maximum 1,000 characters including spaces) FORMTEXT ?????Reviewer nominationsApplicants must nominate three reviewers for this applicationFor nominations to be eligible the Applicant must be able to answer Yes to all questionsYesNo1Are all three nominated reviewers external to MSH and the university school(s)/research institute(s) of all named investigators? FORMCHECKBOX FORMCHECKBOX 2Is at least one nominated reviewer from interstate or overseas? FORMCHECKBOX FORMCHECKBOX 3Are all three nominated reviewers an acknowledged expert in the field of the proposed research (i.e. publication track record, PhD or equivalent research experience)? FORMCHECKBOX FORMCHECKBOX 4Are all three nominated reviewers completely independent of the investigative team (including AIs) and without conflict of interest? (See 2018 Funding Guidelines) FORMCHECKBOX FORMCHECKBOX 5Have all three nominated reviewers agreed to be available from September to October to assess your application? FORMCHECKBOX FORMCHECKBOX 4.1Reviewer 1Name FORMDROPDOWN FORMTEXT First Name FORMTEXT Surname Health profession FORMDROPDOWN Organisation/Institution FORMTEXT Organisation/Institution nameDepartment FORMTEXT Department namePhone number: FORMTEXT ?????Email: FORMTEXT ?????Availability confirmed?Yes FORMCHECKBOX No FORMCHECKBOX Comments (300 characters) FORMTEXT ?????Who contacted this reviewer? FORMTEXT ?????4.2Reviewer 2Name FORMDROPDOWN FORMTEXT First Name FORMTEXT Surname Health profession FORMDROPDOWN Organisation/Institution FORMTEXT Organisation/Institution nameDepartment FORMTEXT Department namePhone number: FORMTEXT ?????Email: FORMTEXT ?????Availability confirmed?Yes FORMCHECKBOX No FORMCHECKBOX Comments (300 characters) FORMTEXT ?????Who contacted this reviewer? FORMTEXT ?????4.3Reviewer 3Name FORMDROPDOWN FORMTEXT First Name FORMTEXT Surname Health profession FORMDROPDOWN Organisation/Institution FORMTEXT Organisation/Institution nameDepartment FORMTEXT Department namePhone number: FORMTEXT ?????Email: FORMTEXT ?????Availability confirmed?Yes FORMCHECKBOX No FORMCHECKBOX Comments (300 characters) FORMTEXT ?????Who contacted this reviewer? FORMTEXT ?????4.4Excluded ReviewersIf relevant, list details of up to two reviewers you would like excluded from assessing your application and provide justification for their exclusionExcluded Reviewer 1Name FORMDROPDOWN FORMTEXT First Name FORMTEXT Surname Health profession FORMDROPDOWN Organisation/Institution FORMTEXT Organisation/Institution nameDepartment FORMTEXT Department nameJustification FORMTEXT Provide detailsExcluded Reviewer 2Name FORMDROPDOWN FORMTEXT First Name FORMTEXT Surname Health profession FORMDROPDOWN Organisation/Institution FORMTEXT Organisation/Institution nameDepartment FORMTEXT Department nameJustification FORMTEXT Provide details5Agreements and Certification of SupportCERTIFICATION BY THE Principal INVESTIGATORPlease carefully read each criterion and ensure the application complies. Ticking each indicates your certification of each criterion. Incomplete applications may be deemed ineligible.I, certify that: Written agreement (such as an email) has been obtained from all investigators named in this Research Support application and that all details provided are correct. FORMCHECKBOX I understand that should this application be successful, all named Co-Investigators on this application will be required to sign the Acceptance of Offer. FORMCHECKBOX On behalf of the investigative team, we accept and agree to comply with the ethical standards as set out by the National Health and Medical Research Council, and any additional standards required by the appropriate Human Research/Animal Ethics Committee (including, but not limited to the National Statement on Ethical Conduct in Human Research and Australian Code for the Responsible Conduct of Research). FORMCHECKBOX Research will not commence until all ethical clearances and site specific approvals (SSAs), if required, have been obtained. FORMCHECKBOX I acknowledge and accept that grant payments from SERTA can only be made to a Metro South Health (MSH) employee, and must be deposited into a MSH research cost centre. FORMCHECKBOX The research team meets the relevant eligibility criteria for the Research Support Scheme and all mandatory questions have been answered. FORMCHECKBOX Progress reports (Ethics and Projects) must be provided annually and / or a final report must be provided at the end of the support period FORMCHECKBOX On behalf of the investigative team, we accept and agree to comply with Metro South Health. Policies and Procedures and requests from the Centres for Health Research – Metro South Health in the management of these grants. FORMCHECKBOX FORMTEXT ?????Name of ApplicantSignature FORMTEXT DD/MM/YEARDate:6CERTIFICATION BY Head(s) of Division/DepartmentI certify that:The proposed research is appropriate to the general facilities in my Division/Department and that I am prepared to have the project carried out in my Division/Department.Experiments involving humans/animals (will) conform to the general principles set out in the National Health and Medical Research Committee’s National Statement on Ethical Conduct in Human Research/Australian Code of Practice for the Care and Use of Animals for Scientific Purposes FORMTEXT ?????Name of Head of Department (print):Signature FORMTEXT DD/MM/YEARDate: FORMTEXT ?????Name of MSH site/university school:Note: If the Head of Department is also the Principal Investigator then he / she cannot provide certification. Certification must then be given by the Head of Department’s supervisor. ................
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