Academic activity



Association of British NeurologistsClinical Research Training Fellowship ApplicationElectronic submission deadline 23:59 17 November 2019 to: admin@.uk ApplicantSurname ForenameCorrespondence addressTelephonee-mailPrimary supervisor NameCorrespondence addressTelephonee-mailResearch institution/organisation NameFinance officerCorrespondenceaddressTitle of project (Maximum 120 characters, in mixed case, including spaces and punctuation) THE APPLICANTSurname ForenameAcademic and Higher Professional Qualifications (starting with most recent)Academic InstitutionQualificationClassSubjectYear of AwardOther Relevant Society MembershipCompetitive prizes/awards with datesFull employment history, including present position (include end date for current contract). List should start with current post and read in reverse chronological order. Department & InstitutionPost held(including source of funding for any research appointments)From(dd/mm/yy)To(dd/mm/yy)Research experience (briefly list relevant experience e.g. BMedSci or equivalent, details of any training, technical skills)Publications (list only published or in press peer-reviewed publications. Include all authors with your name highlighted in bold, title, journal, year, pagination and PMID)Other applicationsPlease indicate if you have applied for other fellowships (*delete as applicable) and, if so, provide any known interview dates.*No, I have not applied for other fellowships*Yes, I have applied for other fellowships as detailed below Awarding organisationInterview dateTHE PROJECTTitleProposed start dateDuration in monthsAbstract of research (Up to a maximum 250 words, please summarise the central research question, key aims, methodology, and the scientific and clinical implications of the study.)Lay summary (maximum 250 words, explain to a lay audience the nature of the proposed research. This must include the expected benefits in terms of improvement to human health, with an estimate of the time frame to any clinical translation). Details of the project (maximum 1500 words)Include (a) Hypotheses (NB not a prediction of results), (b) Background to the proposal, (c) Experimental design and methods (ensure sufficient detail, including a statement on power calculation where relevant), (d) Timetable with key milestones, (e) Potential barriers and mitigationBibliography (maximum 20 references, numbered consecutively as they appear in the text, including first author only, title, journal, year, pagination and PMID) 2730500-341058500SUPERVISION AND ENVIRONMENTPrimary supervisor NameInstitutionAcademic activityApproximate grant income in the last five years ?Total number of PhD students supervised to date?How many other students will be in supervision at the same time as this project?Supervisor’s publications List up to 10 peer-reviewed papers relevant to the proposal (include all authors with supervisor highlighted in bold, title, journal, year, pagination and PMID)Suitability of the research training environment (maximum 250 words)List the research training and key personnel who will deliver it (maximum 250 words) Co-supervision arrangements and any external collaborations (maximum 250 words) ETHICAL AND REGULATORY DETAILSHuman researchResearch ethics committee approval:Approved?REC number: Submitted?Date decision due: Not yet submitted?Estimated date of submission: Not applicable?NHS service support costs (Where the proposed research draws on NHS facilities, it is likely to incur service support and/or excess treatment costs which the NHS is obliged to meet).Has the funding to service support costs been guaranteed by the appropriate NHS provider(s)?Has the funding for excess treatment costs been approved by the appropriate NHS provider(s)?Animal researchDoes the proposed research involve the use of vertebrate animals or other organisms covered by the Animals (Scientific Procedures) Act (MANDATORY)If YES, in section F4 (Research to be undertaken), please provide details of any areas of substantial/moderate severity.If YES, please provide details of any areas of substantial/moderate severity.Are the appropriate Home Office Project Licences in place?Are the appropriate personal licences in place?Has the application already been approved through a local ethics process regarding the use of experimental animals?Please outline the justification for the use of animals and how are the 3Rs addressed? (Maximum 250 words) FINANCEA The FellowSalary costsYr 1?Yr 2?Yr 3?Total?B Travel costs (registration, economy travel and accommodation)ConferenceYr 1?Yr 2?Yr 3?Total?C Equipment Brief description of item(NB avoid generic terms e.g. consumables)Basic price ?Total?D Other costs DescriptionYr 1?Yr 2?Yr 3?Total?SummaryTotal costsYr 1?Yr 2?Yr 3?Total ?Total salary (A above)Total consumables (B, C, D above)Final totalJustification of costsJustify all financial resources requested (maximum one side of A4)SUPPORTING STATEMENT OFPRIMARY SUPERVISORPrimary supervisor nameHow long have you known the applicant?State your views on the applicant’s scientific ability and suitability for this Fellowship (maximum 250 words). SUPPORTING STATEMENT OFHEAD OF DEPARTMENTHead of Department nameSurname State your views on the merits of the combination of the applicant, supervisor and project within your Department (maximum 250 words). ARRANGEMENTS FOR MENTORINGPlease describe arrangements for the Fellow’s mentoring which will be put in place should an award be offered and accepted. This may include details of mentoring schemes already in place in your research organisation (maximum 250 words).DECLARATION AND SIGNATORIESIn submitting this research proposal, we confirm that:APPLICANTIf a Fellowship award is offered, I will accept it and abide by the Terms and Conditions and any subsequent amendments of the charity or charities providing the funding.I have not entered into any obligations which would conflict with the Terms and Conditions of the charity or charities providing the funding.Signature:Name:Date:PRIMARY SUPERVISORI undertake to provide regular academic supervision of the applicant I will ensure timely submission and co-signature of the applicant’s progress reportsSignature: Name: Date:HEAD OF DEPARTMENTThe department will ensure that mentoring arrangements are put in place as described.The department will meet any?shortfall in consumable costs necessary for the completion of the candidate's?project.Signature:Name:Date:ADMINISTERING AUTHORITYIf the Fellowship is awarded and accepted the candidate will be offered an appointment, subject to the administering authority’s normal employment practices, for the full tenure of the Fellowship.If the Fellowship is awarded and accepted the administering authority will abide by the Terms and Conditions and any subsequent amendments of the awarding charity or charities. The applicant’s grade and salary quoted are correct and in accordance with the normal practice of this institution.Signature:Name: Date: ................
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