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NHMRC Practitioner Fellowships Full Application Form 2009
When completing this full application form, please refer to the NHMRC Practitioner Fellowships Guide for Applicants for Support Commencing January 2010 available on the internet at: http://www.nhmrc.gov.au/grants/apply/career/index.htm#b All information should be completed in Times New Roman 12 point. Applicants that do not comply with this font size requirement may be deemed ineligible. All applications must be LODGED ELECTRONICALLY via the Research Administration Officer (RAO) of your Administering Institution. HARD COPIES of applications are no longer required. The RAO should email the application to research.fellowships@nhmrc.gov.au or send the application to NHMRC on a compact disc (refer to „Submission of Applications‟ in the Practitioner Fellowships Guide for Applicants for Support Commencing January 2010). All documents are to be converted into PDF from the original electronic document. All attachments to the application must be included in a single Adobe Acrobat PDF file. The application is to be submitted as a single pdf file, ensuring that each of the three sections (A, B and C) commences on a new page. The following naming convention must be used in the document name (do not include spaces) “[APPID]_[Applicant‟s Surname].pdf”. Applications must be received by close of business AEST 6 February 2009.

LATE OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

NHMRC Practitioner Fellowships Application – 2009 (Section A)

SECTION A - APPLICANT INFORMATION

1.

NAME AND CONTACT DETAILS

Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Courier address (Line 1): Courier address (Line 2): Suburb/Town: State: Postcode: Phone (office): Fax: Mobile: Email:

2.

DATE OF BIRTH, GENDER

Date of Birth: Gender:

3.

CITIZENSHIP

Citizenship: If not an Australian citizen, has permanent resident status or a Special Category Visa been sought? Has permanent resident status or a Special Category Visa been granted?

NHMRC Practitioner Fellowships Application – 2009 (Section A)

Application ID:

4.

ABORIGINALITY AND/OR TORRES STRAIT ISLANDER STATUS Please indicate whether you are Aboriginal and/or Torres Strait Islander. An Aboriginal or Torres Strait Islander is: A person of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander. Data on the Aboriginal or Torres Strait Islander status of people involved with NHMRC grants is being collected to allow the NHMRC to determine the extent of Aboriginal or Torres Strait Islander participation in NHMRC funded health and medical research. This information is then used to inform the development of NHMRC policy and strategy.

YES

NO Check box as appropriate

5.

ACADEMIC QUALIFICATIONS

Most recent academic qualifications:

6.

ADMINISTERING INSTITUTION

Name: Postal address (Line 1): Postal address (Line 2) Suburb/Town: State: Postcode:

7.

ACTUAL INSTITUTION AND DEPARTMENT

At what Institution will the research be conducted? (Department): Justification for choosing this Institution:

8.

ACCESS TO FACILITIES

Will you require access to any of the facilities currently funded under the NHMRC

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: Enabling Grants Scheme? If yes, do you have an agreement from the facility to use the required resource?

9.

CURRENT APPOINTMENT/S

Starting with your main appointment, provide details of date of appointment, level of appointment and address (if different from information provided in Question 1). Also advise on the status of the appointment, eg. whether tenured, non-tenured, non-continuing or other (specify). If you plan to change laboratory or workplace location, indicate the reasons for the proposed change and identify the benefits of the new position. Copy and paste then complete the table below as many times as required if several appointments are held Appointment: Level of Appointment: Address (if different from information provided in Q1): Current status of position (i.e. tenured, non-tenured, non-continuing), If other, then specify: If a change in current laboratory location or workplace is intended, provide the reasons and benefits for doing so:

10.

AREAS OF RESEARCH (REFER TO RESEARCH FELLOWSHIP GUIDE FOR APPLICANTS FOR LISTS AND WEB LINKS)

Broad Research Area: Select only one area Field of Research: Select only one field

Socio-economic Objectives: Select at least one but no more than five objectives

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: Keywords/Phrases – to describe the field of research more specifically Select at least three but not more than five keywords/phrases from EACH of the lists referred to in the Guide to Applicants For summary purposes and possible media release, provide one or two sentences that best encapsulate your research activity. (For example: „I am a neuroscientist/cell biologist determining the molecular mechanisms of synaptic transmission.‟)

11.

BURDEN OF DISEASE/NATIONAL RESEARCH PRIORITIES

As applicable, indicate the percentage of the research activity to be spent on each sub-group of the Burden of Disease category and National Research Priority. The percentage given in each table may separately total 100%. This question requests information to assist the NHMRC in data collection. Funding is not conditional on the research addressing one or more of the Burden of Disease categories or National Research Priorities. Assessment criteria do NOT include the relevance of an application to the Burden of Disease category and National Research Priorities.

BURDEN OF DISEASE Category Asthma Respiratory conditions-acute and chronic Cardiovascular disease Cancer - Malignant neoplasms Benign neoplasms/myomas Congenital abnormalities Diabetes mellitus Endocrine and metabolic Diseases of the digestive Genitourinary (including kidney) diseases Infectious and parasitic diseases Injuries - Unintentional and Intentional Maternal conditions, foetal development and neonatal disorders Mental disorders

Percentage (%)

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: Alzheimer‟s disease and other dementias Sense Organ disorders Nervous system disorders Arthritis Osteoporosis Other Musculo-skeletal conditions Nutritional deficiencies Oral health Skin diseases (excluding skin cancer/melanoma) Other Ill-defined conditions Immunity, immunology not elsewhere classified Genetics –developments, defects, inherited conditions and therapies not elsewhere classified Health services research, Public health matters and epidemiology not elsewhere classified

NATIONAL RESEARCH PRIORITIES Priority Goal NRP Percentage (%)

A healthy start to life Ageing well, ageing productively Preventative healthcare Strengthening Australia‟s social and economic fabric Breakthrough science Frontier technologies Advanced materials Smart information use Promoting an innovation culture and economy Critical Infrastructure Understanding our region and the world Protecting Australia from invasive diseases and pests Protecting Australia from terrorism and crime Transformational defence technologies Water – a critical resource Transforming existing industries Overcoming soil loss, salinity and acidity Reducing and capturing emissions in transport and energy generation Sustainable use of Australia‟s biodiversity Developing deep earth resources Responding to climate change and variability

Promoting and maintaining good health Promoting and maintaining good health Promoting and maintaining good health Promoting and maintaining good health Frontier Technologies for building and transforming Australian industries Frontier Technologies for building and transforming Australian industries Frontier Technologies for building and transforming Australian industries Frontier Technologies for building and transforming Australian industries Frontier Technologies for building and transforming Australian industries Safeguarding Australia Safeguarding Australia Safeguarding Australia Safeguarding Australia Safeguarding Australia An environmentally sustainable Australia An environmentally sustainable Australia An environmentally sustainable Australia An environmentally sustainable Australia An environmentally sustainable Australia An environmentally sustainable Australia An environmentally sustainable Australia

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: 12. HISTORICAL INFORMATION

If applying for a Promotion out of synchrony, initial five- year appointment or Second five-year appointment with Promotion, provide answers to the following three dot points Year first appointed to the scheme: Level on initial appointment: Date promoted to present level (if applicable):

13.

PREVIOUS APPOINTMENTS

Briefly itemise previous appointments in chronological order (details of these appointments and their relationship to scientific outcomes can be expanded in the detailed CV Period of Appointment: Appointment: Institution

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: 14. TYPE AND LEVEL OF FELLOWSHIP SOUGHT (current level and type/level of Fellowship sought)

Type (Initial Appointment, initial five-year appointment, Second five-year appointment with Promotion or Promotion out of synchrony:(Note that any
application for a second 5 year appointment will be treated as a new application in the same way as an initial appointment)

Current Level (PF1 or PF2): Level sought in application: If applying for Initial Appointment at PF 2, provide relevant justification: (note that applications for Initial Appointment at PF 2 may also be considered for a PF 1 if they do not meet the requirements of the higher level)

15.

PERCENTAGE OF TIME REQUESTED FOR PRACTITIONER FELLOWSHIP

Indicate the percentage of time (30-70%) that you will devote to the research associated with this application: Indicate the relative proportions of time to be spent on research and clinical or public health practice:

Research %

Clinical %

Public health practice %

16.

SOURCE AND DURATION OF CURRENT SALARY SUPPORT

Indicate ALL sources from which your current income is derived. Also indicate the duration of each component of salary support. Source Duration

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID:

17.

PROPOSED FUNDING PARTNER FOR PRACTITIONER FELLOWSHIP SALARY A written undertaking from the organisation identified as the proposed funding partner (in relation to provision of salary and time available for research) MUST be attached to your application.

Name: Postal address (Line 1): Postal address (Line 2) Suburb/Town: State: Postcode:

18.

TITLE, SOURCE AND DURATION OF FUNDING

Title: Source of Funding: Duration of funding:

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID:

SECTION B – RESEARCH SUMMARY
19. EXECUTIVE SUMMARY

This should be included as one page only in the space provided. All pages exceeding the page limit will be removed.

On the following page, summarise the most compelling evidence supporting your application, with reference to the specific selection criteria: NOTES: 1. Do not include an outline of your research plan in this section as that is to be addressed under the ‘Research Proposal for which Part-Package is Sought’ Refer to the Guide for Applicants for further explanation

2.

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: EXECUTIVE SUMMARY

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: 20. DETAILED CURRICULUM VITAE

(a)

Academic background:

(b)

Postgraduate training:

(c)

Current (and proposed if different from current) appointments:

(d)

Past and current collaborations:

(e)

Absences:

(f) Local, national and international profile Identify the audience to which any talks was given or the size of the conference in which you participated using the following criteria as relevant to each and identify if of a national or international nature: departmental; institutional; or conference. With respect to attendance at international conferences indicate what percentage of your travel was financed by the conference organiser

(g)

Postgraduate and undergraduate teaching:

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: (h) Clinical responsibility:

(i)

Administrative responsibilities:

(j)

Peer review involvement:

(k)

Scientific discipline involvement:

(l)

Involvement in the wider community:

(m)

Previous and current research experience: (up to three pages – form commences on the following page)

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: PREVIOUS AND CURRENT RESEARCH EXPERIENCE – Page 1

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: PREVIOUS AND CURRENT RESEARCH EXPERIENCE – Page 2

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: PREVIOUS AND CURRENT RESEARCH EXPERIENCE – Page 3

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID:

(n)

Other relevant data:

21.

RESEARCH PLAN

Provide a brief (not in excess of three pages) detailing your Research Plan: The brief must:  include evidence of grant support for the proposal and must describe:  the relationship of this research to your professional practice

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: RESEARCH PLAN – page 1

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: RESEARCH PLAN – Page 2

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: RESEARCH PLAN – page 3

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID:

22.

ANALYSIS OF CLINICAL WORK/RESEARCH LINK

Provide a brief summary (not excess of one page) detailing the link between your clinical work and research: The summary must describe:  the links between your clinical work and your research  your approach to research transfer and implementation of outcomes  synergies created by your combined research/practice career.

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: LINK BETWEEN CLINICAL WORK AND RESEARCH

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID: 23. RESEARCH SUPPORT SUMMARY

Failure to provide detailed information about research grant support as requested below, including your role in the research, may jeopardise the assessment of your application

NHMRC Grants (a) All Past support:

(b)

Currently held grants:

(c)

Grants requested for funding in 2010:

Other Sources (a) All past support:

(b)

Currently held grants:

(d)

Grants requested for funding in 2010:

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID:

24.

PUBLICATIONS

(i) (i)

FULL LISTING OF PUBLICATIONS

List all publications from both NHMRC and non-NHMRC funding showing details of articles that have been accepted or published or books that have been published or are in press. Include detail relating to articles that have been withdrawn or retracted and annotate them as such. You may also indicate the number of times the paper has been cited. (Order from the earliest date, include information on your role in multi author papers and sort into research publication sub categories outlined in the Guide to Applicants).

(ii) (ii)

MOST SIGNIFICANT PAPERS

Include brief comments on up to four of the most significant papers you have published (copies do NOT need to be included in your application)

NHMRC Practitioner Fellowships Application – 2009 (Section B)

Application ID:

SECTION C – ASSESSMENT AND REPORTING
External Assessors will NOT receive any of the information contained in Section C

25.

NOMINATION OF POSSIBLE ASSESSORS BY APPLICANT

Provide the names and full contact details for eight available assessors appropriate to comment on your Fellowship application. Endeavour to include four international assessors. Assessor 1: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: Previously collaborated: Yes/No Reason for selection of this Assessor: Assessor 2: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: Previously collaborated: Yes/No Reason for selection of this Assessor: NHMRC Practitioner Fellowships Application – 2009 (Section C)

Application ID:

Assessor 3: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: Previously collaborated: Yes/No Reason for selection of this Assessor:

Assessor 4: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: Previously collaborated: Yes/No Reason for selection of this Assessor:

Assessor 5: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: NHMRC Practitioner Fellowships Application – 2009 (Section C)

Application ID: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: Previously collaborated: Yes/No Reason for selection of this Assessor:

Assessor 6: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: Previously collaborated: Yes/No Reason for selection of this Assessor:

Assessor 7: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: NHMRC Practitioner Fellowships Application – 2009 (Section C)

Application ID: Previously collaborated: Yes/No Reason for selection of this Assessor:

Assessor 8: Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Country Phone (office): Fax: Mobile: Email: Area of expertise: Previously collaborated: Yes/No Reason for selection of this Assessor:

NHMRC Practitioner Fellowships Application – 2009 (Section C)

Application ID:

26.

NOMINATION OF A NON-ASSESSOR

If you wish to nominate a particular assessor NOT to be approached to assess your application, provide their contact details (limit 1 assessor). Refer to criteria in Practitioner Fellowships Guide for Applicants for criteria.

Title: Family name: Given name/s: Postal address (Line 1): Postal address (Line 2): Suburb/Town: State: Postcode: Phone (office): Fax: Mobile: Email:

Provide justification for nominating this person as a non-assessor:

27. a)

CERTIFICATION CERTIFICATION BY HEAD OF DEPARTMENT, OR EQUIVALENT

I certify that appropriate general facilities will be available if the applicant is successful and that I am prepared to have the Research Fellowship carried out strictly in accordance with the current NHMRC Deed of Agreement for NHMRC Researcher Support Schemes. Family name Title First or given names Appointment

Department (if applicable)

Organisation

Signature

Date

NHMRC Practitioner Fellowships Application – 2009 (Section C)

Application ID: b) CERTIFICATION BY RESPONSIBLE OFFICER AT ADMINISTERING INSTITUTION

I certify that this request satisfies all the requirements of this Institution, and that this Institution has established administrative processes for assuring sound scientific practice in accordance with the „NHMRC Statement on Scientific Practice‟. Responsible Officer: Family name

Title

First or given names

Signature:

Date:

c)

CERTIFICATION BY APPLICANT

In signing this page you certify that all details given in this application are correct. Applicant family name Title First or given names Signature:

Date:

d)

VERIFICATION BY RESEARCH ADMINISTRATION OFFICER

I verify that I have checked this application and that, to the best of my knowledge, all relevant details are correct at the time of lodgement with the NHMRC. Research Administration Officer: Family name Title

First or given names

Signature

Date

NHMRC Practitioner Fellowships Application – 2009 (Section C)

Application ID:

CERTIFICATION BY RELEVANT AUTHORISED OFFICER FOR PART-TIME RELEASE TO CONDUCT RESEARCH I agree to make available to: Family name Title First or given names Appointment

Institution

The following percentage time per week to conduct the research associated with this Practitioner Fellowship proposal. % time per week available

This is associated with the following part-time complementary salaried position for 2006. Position Institution

I note that annual renewal of the Award is conditional upon the Awardee‟s continued employment in a complementary salaried position. Certified by: Family name Title First or given names Appointment

Institution

Signature

Date

NHMRC Practitioner Fellowships Application – 2009 (Section C)