CLINICAL RESEARCH FELLOWSHIPS

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                                                                      Grant ID #: 08 / CRF/ _ _ _




       CLINICAL RESEARCH FELLOWSHIPS
                                 ~APPLICATION FORM A~
    (To be used when joint application is being made by the proposed Fellow and the Institution/s)


                   CLOSING DATE: 5 September 2008
Note: All sections of this application must conform to the following: Double sided, A4 paper; 2cm margins on
each side and at least 12 point font (preferred fonts are Times New Roman, Arial and Helvetica).

  SECTION A – ADMINISTRATIVE SUMMARY

  A.1 Administering Institution




  A.2 Application Title
  Provide a short descriptive title. No more than 20 words.




  A.3 Applicant


  Surname

  First Name                                                            Title

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  A.4 Actual Institutions
  In some cases the Institution that will administer your application may differ from the Institution in
  which you will actually conduct the proposed research. Please list all institutions where the research
  will be carried out.


  A.5 Lay Project Summary
  In lay terms summarise the research, referring to aims, significance and expected outcomes suitable
  for Cancer Institute NSW website and media release No more than 200 words.




  A.6 Broad Research Area
  Please indicate what percentage of this grant falls under each category (must add up to 100%).

   Basic Science                             %         Research Public Health               %
   Clinical Medicine & Science               %         Psychosocial/Behavioural             %
   Health Services                           %         Preventative Medicine                %

  A.7 Clinical Groupings
  Enter relevant groupings (e.g. skin; head & neck) from list available at Clinical Groupings and
  Common Scientific Outline and allocate percentage (must add up to 100%) (tab to add more lines if
  required).

   Grouping              %    Grouping         %    Grouping           %      Grouping           %


  A.8 Common Scientific Outline (CSO)
  Enter relevant CSO codes (e.g 2.1, 3.4 etc.) from list available at Clinical Groupings and Common
  Scientific Outline and allocate percentage (must add up to 100%) (tab to add more lines if required)

   CSO            %        CSO         %     CSO          %     CSO         %      CSO          %


  A.9 Type of NHMRC Fellowship applied for:
  (applicable for concomitant NHMRC and Cancer Institute NSW applications only)

   Fellowship
   Salary level
   Provide title of
   NHMRC research
   proposal
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  SECTION B – BUDGET & JUSTIFICATION
  B.1 Budget for Research Component of the Fellowship
  Maximum of $100,000 per annum.

                                          Detail (Type of
                                           personnel,            Year 1          Year 2     Year 3
    Budget Item                            equipment
                                               and
                                          consumables)
    Personnel (not Fellow)

    Equipment
    Necessary Travel
    (e.g., for collaborations,
    attendance at
    conferences)
    Maintenance
    Other expenses (not
    overheads)

    TOTAL


  B.2 Budget Justification.
  Budget items must be justified in terms of need and cost in respect to the project plan. (Maximum 1
  page).




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  B.3 Salary Budget for Fellow

                                                     Year 1             Year 2              Year 3
     Salary

     Fellow Salary

     On Costs

     TOTAL


     Please justify salary level (to be signed off by Head of Research Institute in section C.5.)

     Level:

     Justification:




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  SECTION C – CERTIFICATIONS

  Privacy Notice

  Applicants (researchers and research institutions) consent to the information supplied as part of their
  application being disclosed for the purposes of the assessment of their application and for purposes
  connected with the making and administration of the Fellowship. Such disclosure includes, but is not
  limited to, disclosure to members of the Grants Review Committee, independent readers/assessors
  requested to provide advice, and relevant representatives and employees of the Cancer Institute
  NSW research programs process. Documents containing personal information are handled and
  protected in accordance with the provisions of the Privacy and Personal Information Protection Act
  1998 which sets standards for the collection, storage, use and disclosure of, and access to, personal
  information.

  C.1 Applicant

  Certification by the Applicant
  I certify that:

  1.    To the best of my knowledge and belief, information contained in this application is complete,
  true and correct and I understand that the provision of false or misleading information may attract
  substantial penalties.

  2.     I consent to this application being peer-reviewed by persons who will remain anonymous.

  3.     I have read and agreed to the Privacy Notice above.



   Name of Applicant                             Signature                        Date




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  C.2 Administering Institution

   Institution

   ABN

  Administering Institution contact person for management of the grant and funding (This
  would be a nominee from the Research Office or Finance Department; it can not be the applicant
  themselves).

   Name

   Title

   Address

   Email

   Phone no.


  C.3 Certification by the Administering Institution

  I certify that:

  1.     I am authorised to sign the application form on behalf of this Administering Institution.

  2.   All funds awarded for the Fellowship will only be spent in accordance with the executed
  agreement and original application.



   Name

   Title

   Signature

   Date




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  C.4 Research Institution and Department
  Name and full address of the research institution and department in which the research will be
  undertaken.

   Department

   Institution

   Address

  C.5 Certification by the Head of the Research Institution (or delegate)
  I certify that:
  1.     I am authorised to sign the application form on behalf of this research institution.
  2.   I am prepared to have the Cancer Institute NSW Clinical Research Fellowship carried out in
  my institution/organisation under the circumstances set out in this application.
  3.    To the best of my knowledge and belief, information contained in this application is complete,
  true and correct and I understand that the provision of false or misleading information may attract
  substantial penalties.
  4.     The Fellowship will be accommodated within the general facilities of this
  institution/organisation, and appropriate infrastructure is available.
  5.   I certify that the salary outlined in the Budget Section B.3: Salary budget for Fellow is the
  correct remuneration package for the Fellow in line with current employment awards within the
  Research Institute.
  6.   The Fellowship will not be permitted to proceed until ethics clearance(s) (where appropriate)
  have been obtained.



   Name

   Title

   Signature

   Date




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  SECTION D - APPLICANT INFORMATION

  D.1 Personal Details of Applicant
  The contact details should be those that apply when the application is submitted so the Cancer
  Institute NSW can, if necessary, contact the researcher.

  Title

  Given names

  Family name

  Work Address

  Work Phone

  Mobile

  Email

  Citizenship*

  *Non-Australian Citizens/Non-Permanent Residents are welcome to apply. You will need to provide
  proof of residency to the Cancer Institute NSW if successful.


  D.2 PhD Qualification Awarded
   Discipline/Field
   Organisation
   Country
   Month and Year                                  (or) Date Thesis
   awarded                                         Submitted/Proposed
   mm/yyyy):                                       Submission Date


  D.3 Other Qualifications (including highest Qualification if not PhD).
      Degree/Award                 Year         Discipline/Field        Organisation and Country




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  D.4 Academic, Research, Professional and Industrial Experience
  - Current and previous appointment(s)/position(s) during the past 10 years.

        Position held             Organisation       Department         Year Appointed and
                                                                       Status (eg fixed term,
                                                                           ongoing etc)




  D.5      Career Research Objectives
  Outline your career development objectives for the next five years and relate these to the
  development of your research career and the purpose. (Maximum 1 page).




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  D.6      Career Achievements and Awards
  For example, patents, prizes, distinctions, honours, awards and other professional activities.
  Other experiences and commitments should also be mentioned. (Maximum ½ page).




  D.7 Any aspects of your career or opportunities for research that are relevant to
  assessment and that have not been detailed elsewhere in this application
  For example, interruptions to career, any other circumstances that may have slowed down your
  research and publications. (Maximum ½ page).




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  D.8 Research Support
  List research support history. Asterisk any support related to this project. Add more pages if
  necessary (C-Current R-Requested and P-Past).

   All named investigators          * C       $(000)    $(000)     $(000)      $(000)     $(000)
   on any Proposal or                   R      2005      2006       2007        2008       2009
   grant/project/fellowship             P
   on which the applicant
   is involved; project title;
   funding body; scheme.




  D.9 Statements of Progress for Cancer Institute NSW Funded Projects
  Include a statement detailing progress for each grant you are named on funded by the Cancer
  Institute NSW that received funding in 2007. (Maximum 1 page per project.).




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  D.10 Attach a List of all Publications (in the past five years). Use asterisks to identify
  publications relevant to this application (include books, book chapters, referred journal articles
  and refereed conference papers – excluding abstracts). You may include impact factors and
  citation information if desired.
  Start the list with your top 5 career publications.


   1


   2


   3


   4


   5




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  SECTION E – RESEARCH PROPOSAL
  Please provide the following information under each heading below (no more than 8 pages in
  total) in relation to the proposed project/programme of research activity to be undertaken.


  APPLICANTS MUST USE THE HEADINGS LISTED BELOW.

  E.1 Aims
  Clearly detail the aims and objectives of the proposed project/program of research.


  E.2 Background
  Include information about recent international progress in the field of the research, and the
  relationship of this proposal to work in the field generally.

  Refer only to refereed papers that are widely available to national and international research
  communities.

  E.3 Significance and Innovation
  Describe how the research is significant and the importance of the problem it addresses.

  Describe how the anticipated outcomes advance the knowledge base of the discipline and why
  the research activity, aims and concepts are novel and innovative.

  Detail what new methodologies or technologies will be developed.

  E.4 Milestones
  Provide a timetable for the research, including research milestones against which the progress of
  the Fellowship can be measured (add lines if necessary).

            Milestone                                                  Achievement date
                                                                       (mm/yyyy)
     1
     2
     3

  E.5 Approach
  With reference to the milestones, outline the conceptual framework, design and methods
  demonstrating that these are adequately developed, well integrated and appropriate to the aims
  of the research activity.

  E.6 Goals of the Cancer Institute NSW
  Describe how the research might impact on 1 or more of the Goals of the Cancer Institute NSW

  E.7 Communication of Results
  Outline plans for communicating the research results.

  E.8 References
  Include a list of all papers referenced in this section. Included in the 8 page limit.




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  SECTION F – CLINICAL PRACTICE
  NOTE: Majority of the time of this Fellowship is to be spent on Research. Appendix 3 must be
  completed by the Head of the institution at which you are conducting clinical practice, to certify
  release for part-time research.
  F.1 What is the source of your current salary?
  University, hospital, NHMRC (or other granting agencies) or private practice funds? If
  appropriate, specify proportion of funds drawn from each source
     Source                                                                              %




  F.2 Who currently administers your salary e.g. hospital, educational institution or
  private practice?



  F.3 How many years have you been employed under
      the above award?


  F.4 What percentage of your time is currently devoted to
      clinical research?


  F.5 If successful, what percentage of your time will be given
      over to clinical practice?


  F.6 Briefly explain how will you manage your clinical responsibilities in order to
      take up a fellowship position? (maximum 1 page).




  F.7 Briefly describe the relationship between proposed research and your clinical
      practice? (maximum 1 page).




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  SECTION G – REQUIRED REPORTS AND REFERENCE
  The Cancer Institute NSW will treat all reports in-confidence.

  G.1 Report from Head of Proposed Laboratory/Department or other Workplace
  where work is to be carried out.
  This person must comment on the facilities that will be available to the researcher and the
  mentoring arrangements that will be in place to support the development of his/her career.
          Use the form in Appendix 1.
          This report must be completed and signed by the Head of the
           laboratory/department where the work is to be carried out.
          The report must be submitted with this application.

  G.2 Certification from Head of the Clinical Practice Institution
  This person must guarantee the release of the applicant to conduct proposed part-time clinical
  research. This person must also agree to provide the salary for clinical practice component of the
  Fellowship unless requested in this application.
          Use the form in Appendix 2.
          Please note that the application may be made to allow the majority of the
           applicant’s time in clinical research.
          The certification must be submitted with this application

  G.3      Report from Head of Current Laboratory/Department or other Workplace
  This person must comment on your current research capability (relative to the research
  opportunities you have had) and your future research potential relative to the objectives of the
  Cancer Institute NSW Clinical Research Fellowship.

  Full Name
  Institution

          Use the form in Appendix 3.
          This report must be completed and signed by the Head of current
           Laboratory/Department.
          The report must be submitted directly to the Research Secretariat, Cancer
           Institute NSW by COB 5th September 2008.

  G.4 Referee Report
  This person must comment on your research contributions, potential as a researcher and provide
  an assessment of any other selection criteria.

  Full Name
  Institution

          Use the form and Guidelines to Referee in Appendix 4.
          This reference must be completed and signed by the referee.
          The Referee must submit this report directly to the Research Secretariat,
           Cancer Institute NSW by COB 5th September 2008.




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  SECTION G - APPLICATION CHECKLIST
  The following checklist should be completed prior to submission.

  Incomplete applications will not be accepted.

           APPLICATION
           REFERENCE                                        ITEM                                  √
               No.
  1.
                   C.1          Applicant certification signed and dated.

  2.
               C2 & C.3         Administering Institution certification completed,
                                signed and dated.
  3.
               C4 & C.5         Head of Research Institution certification completed,
                                signed and dated.
                   G1           Report from Head of Proposed
                                Laboratory/Department or other Workplace where
  4.
                                work is to be carried out.

             Appendix 1         -Attached to this application
                G2              Certification from Head of the Clinical Practice
                                Institution
  5.
             Appendix 2         -Attached to this application
                G3              Report from Head of Current Laboratory/Department
                                or other Workplace
  6.
             Appendix 3         -Check with HOD that the report has been provided
                                directly to the Cancer Institute NSW.
                   G4           Referee Report
  7.
                                -Check with Referee that the report has been
             Appendix 4         provided directly to the Cancer Institute NSW.

  8.                            Application e-mailed to Research Secretariat (please
                                refer to “Guidelines for Applicants” for electronic
                                submission instructions).

  9.                            16 copies provided (1 original plus 15 copies), double
                                sided (please refer to “Guidelines for Applicants” for
                                hard copy submission instructions).




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                                                                                             APPENDIX 1
                                 CANCER INSTITUTE NSW
                            CLINICAL RESEARCH FELLOWSHIPS

    REPORT FROM HEAD OF PROPOSED LABORATORY/DEPARTMENT OR OTHER
                             WORKPLACE.


  Applicant Details
  Title
  Given names
  Family name

  Report (not more than 2 pages in total)
  Include a list of equipment, space, research assistance and other laboratory and support facilities
  that will be available to the applicant and an outline of mentoring arrangements.




Name of Head of
Department/Laboratory
Title
Appointment
Institution
Signature
Date

Name of CEO (or
equivalent) of
Research Institution
Title
Appointment
Institution
Signature
Date

  This form must be returned to the applicant to be included with the application due
  by COB 5th September, 2008.

                                       Cancer Institute NSW
                                       Clinical Research Fellowship Grant Application Form – closing 5th September 2008

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                                                                                         APPENDIX 2

          CERTIFICATION BY HEAD OF CLINICAL PRACTICE INSTITUTION FOR
                   RELEASE TO CONDUCT PART-TIME RESEARCH

I agree to make available to:
Name

Title

Appointment

Institution

The following allocation of time per week to conduct the Research and Public
Clinical Practice associated with this Cancer Institute NSW Clinical Research
Fellowship.
% Time/week
Research

% Time/week Public
Clinical Practice

This time is made available in association with the following complementary salaried
position for

Position

Institution

I note that annual renewal of the award is conditional upon the Fellow’s continued
employment in a complementary salaried position.

Certified by:
Name

Title

Appointment

Institution

Signature

Date
This form must be returned to the applicant to be included with the application due
by COB 5th September, 2008
                                   Cancer Institute NSW
                                   Clinical Research Fellowship Grant Application Form – closing 5th September 2008

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APPENDIX 3

                                      CANCER INSTITUTE NSW
                                 CLINICAL RESEARCH FELLOWSHIPS

     REPORT FROM HEAD OF CURRENT LABORATORY/DEPARTMENT OR OTHER
                             WORKPLACE

                         The Cancer Institute NSW will treat all reports in-confidence.

  Applicant Details
  Title
  Given names
  Family name

  Report (not more than 2 pages in total)




Name of Head of
Department/Laboratory
Title
Appointment
Institution
Signature
Date

  Please send the report no later than 5th September 2008 to the Cancer Institute NSW by email
  to: research.secretariat@cancerinstitute.org.au

  Please title the report and use in subject of email as follows:
  CRF_applicants SURNAME           (e.g CRF _SMITH).

  Please send original documents to:

  Research Secretariat                    OR                Research Secretariat
  Cancer Institute NSW                                      Cancer Institute NSW
  Level 1, Biomedical Building                              PO Box 41
  Australian Technology Park                                ALEXANDRIA NSW 1435
  1 Central Avenue
  EVELEIGH NSW 2015.

                                           Cancer Institute NSW
                                           Clinical Research Fellowship Grant Application Form – closing 5th September 2008

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                                                                                           APPENDIX 4
                                CANCER INSTITUTE NSW
                           CLINICAL RESEARCH FELLOWSHIPS

                           REFEREE REPORT – IN CONFIDENCE.
  (Applicant to complete the Applicant Details section below and forward the form to their
  nominated referee with the attached “Guidelines for Completion of Referee Report Form” for the
  Cancer Institute NSW Clinical Research Fellowships).

  Applicant Details
  Title
  Given names
  Family name
  Position
  Institution

  Report (not more than 2 pages in total)




   Nominated referee
   Title
   Given name
   Family
   name
   Phone
   Fax
   Email
   Position
   Department
   Institution
   Address

   Signature
   Date

                                     Cancer Institute NSW
                                     Clinical Research Fellowship Grant Application Form – closing 5th September 2008

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                                  CANCER INSTITUTE NSW
                             CLINICAL RESEARCH FELLOWSHIPS

                                        REFEREE REPORT

         GUIDELINES FOR COMPLETION OF REFEREE REPORT FORM

  Cancer Institute NSW Clinical Research Fellowships are aimed at encouraging the very best
  early cancer researchers to choose cancer as their selected field of research endeavour. The
  Fellowships will provide funding opportunities to develop and support cancer researchers with
  significant research capacity to continue to undertake research, which is of national and
  international significance, within NSW.


  The objectives of the Cancer Institute NSW Clinical Research Fellowship are:
  a. to develop the future leaders of cancer research in NSW,
  b. to provide an opportunity for researchers at an early stage of their career to pursue an
  independent path of enquiry, and
  c. to attract and/or retain the best researchers with significant research potential for NSW.

  Would you please provide a general overall assessment of the applicant’s research experience
  and abilities and comment in more detail as appropriate on:
   the applicant’s academic performance (including their published work and work published in
  cooperation with others);
   the applicant’s research potential and prospects of a future career as an independent cancer
  researcher;
   the research proposal (its scientific quality and the aims of the scheme outlined above).

  Please also add any other comments that you consider relevant to the application.



  Please send the report no later than 5th September 2008 to the Cancer Institute NSW by email
  to: research.secretariat@cancerinstitute.org.au

  Please title the report and use in subject of email as follows:
  CRF_applicants SURNAME (e.g CRF _SMITH).

  Please send original documents to:
  Research Secretariat                        OR        Research Secretariat
  Cancer Institute NSW                                  Cancer Institute NSW
  Level 1, Biomedical Building                          PO Box 41
  Australian Technology Park                            ALEXANDRIA NSW 1435
  1 Central Avenue
  EVELEIGH NSW 2015




                                       Cancer Institute NSW
                                       Clinical Research Fellowship Grant Application Form – closing 5th September 2008

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