Details of How to Plan and Form a Research Institute by wcu17671

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									        Cancer Institute NSW - Clinical Research Grant Application Form - Version 1 2009




                  NSW Clinical Research Grants 2009
                             (Nursing and Allied Health)


Institution: _____________________________

Area Health service (if applicable ) _______________

Applicant’s name: ________________________________


                            APPLICATION FORM

                  CLOSING DATE: 25th JULY 2008



                         This form must be typed and submitted
                             prior to 5pm on the above date

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Table of contents


SECTION A:               Research proposal

SECTION B:               Applicant details

SECTION C:               Supervisor Details

SECTION D:               Budget

SECTION E:               Cancer Service / Institution

SECTION F:               Certification

Appendix 1:              Referee Report Form

Appendix 2:              Checklist for Completion of Referee Report Form




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Please Note:         Application should not exceed the 10 page double – sided limit
                     Attached CVs and additional material should not exceed the
                     stated page limit
Please ensure that you carefully read the guidelines to assist you in completing all
details.
Section A should be jointly completed by the applicant and supervisor.
Section B by the applicant
Sections C, D, E by the supervisor.
Certifications should be completed by the required signatories within the submitting
organisation.

SECTION A – RESEARCH PROPOSAL
This section should be completed by the applicant and the institution supervi sor/ mentor.

A.1      Research Discipline

         Cancer Nursing                       Allied health (please specify discipline)
                                              _______________________________


A.2      Research Title

In 20 words or less provide a short descriptive title.




A.3      Research Area

In 20 words or less provide a short description of the speciality area.




A.4.     Lay Description

In 100 words or less provide a lay description of the nursing/allied health research project,
suitable for inclusion on the Cancer Institute NSW website and media release.




A.5.     Research Summary

Provide a short synopsis of the research aims, methods, significance and expected
outcomes in no more than 200 words, including it’s link with current clinical practice.

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A.6.     Objectives

List the aims and objectives of the research.




A.7.     Research methodology

Describe the proposed methodology including any ethics approval required. Detail the
conceptual framework, design and methods illustrating these are adequately developed, well
integrated and appropriate to the aims and timeframe of the research activity and if
undertaking a quantitative study, include sample size calculations.




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A.8      Significance and innovation

Describe whether the allied health /nursing research is significant and the perceived
importance of the proposed research to patient/client care and/or clinical service/system
innovation. Include information about recent national and/or international progress in the
field of the research, and the relationship of the proposed methodology to work in the field
generally. Refer only to refereed papers that are widely available to national and international
research communities.

Explain how the anticipated outcomes will advance the knowledge base of the discipline.
Detail any proposed new interventions, programs or methodologies likely to be developed (?
new section).




A.9.     Research 12 month project management timeline

Provide a timetable for the research, including milestones against which research progress
will be measured over the 12 month timeframe. Add lines as necessary.

       Milestone                                                 Achievement date
                                                                 (dd/mm/yyyy)
1

2

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3

4

5




A.10 Communication of results

List plans for communicating the research findings to nursing/allied health peers and the
wider cancer workforce.




Applicant details
This section should be completed by the applicant themselves.

B.1      Personal details
Title

Given names

Family name

Current Work Address




Work Phone

Mobile

Email

Australian Citizenship                  I am an Australian Citizen
* Evidence that the applicant is an
Australian Citizen or permanent         I am /I am not of Aboriginal /Torres strait islander
resident of Australia in NSW
should be attached at the end of
this application form.                  I am a permanent Australian resident

Research role                           I will be undertaking the research myself on a part time basis
Please indicate as appropriate
                                        I will be leading and supervising a part time project officer/ other


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                                       staff to undertake the clinical research




B.2      Curriculum Vitae and evidence of Masters degree/equivalent research
You should provide a two page Curriculum Vitae which summarises details of:
    clinical abilities and experience,
    actual or leadership potential in cancer patient/client care,
    evidence of understanding of the patients’ perspective,
    experience/proven ability in multidisciplinary teamwork,
    any prizes, distinctions and/or other special qualifications awarded, and
    any publications of relevance to the research endeavour including items that have
      been accepted for publication or published.

         I have Attached my two page Curriculum Vitae (CV). Please note CVs longer than
         2 pages will not be considered.

         I have attached a certified copy of my Masters degree/equivalent research.

B.3      Research experience

Describe research abilities including previous research experience and projects including any
research supervision undertaken and research publications.




B.4      Learning/career development goals
Please provide details in the table below.

How does the proposed
research project link with your
current clinical practice?



What skills/ knowledge do
you expect to gain from
completing this project?



What proposed training and
or educational activities will
you be undertaking during the
clinical research period?

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How will the proposed
research assist your clinical
developmental/ career
pathway in oncology/
palliative care?
Describe your proposed
career pathway for the
succeeding 2 years following
the Clinical Research Grant.


Applicant’s referees
To support your application please send the report attached in the appendix to two
referee to complete and email directly back to the secretariat by no later than 27
June 2009. Reports may be faxed 02 8374 5778 or emailed to
emma.niccol@cancer.institute.org.au. Please request the referee to put the
“Applicants name, and referee clinical research grant” into the subject of the email.
The Cancer Institute NSW will treat all reports confidentially.

Please complete the details of the 2 referees who will be providing a referee report below

 Referee (1)
 Family
 name                              Given name                            Title
 Phone                             Fax
 Email
 Position
 Institution
 Department
 Address




 Referee (2)
 Family
 name                              Given name                            Title
 Phone                             Fax
 Email
 Position
 Institution
 Department
 Address




SECTION C – SUPERVISOR DETAILS
This section should be completed by the supervi sor in relation to the proposed clinical
research program to be undertaken

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C.1 Personal details of Lead Supervisor
Title

Given names

Family name

Work Address




Work Phone

Mobile

Email


C.2      Curriculum Vitae and evidence of research publications/program management

You should provide a six page Curriculum Vitae (CV) which summarises:
    academic qualifications and expertise, current academic appointment and other
      academic affiliations,
    publication record over last 5 years,
    evidence of leadership/standing in relevant clinical profession,
    experience in multidisciplinary approaches to cancer care,
    any prizes, distinctions and/or other special qualifications awarded, and
    any publications of relevance to the research endeavour including items that have
      been accepted for publication or published.

         I have attached my six page Curriculum Vitae (CV).

C.3      Program need
Please provide details in the table below.

Please describe the
rationale for how the
proposed research will
further cancer patient
outcomes in your
Department/ Unit and/or
the relevant clinical unit

Please detail how the
proposed research aligns
with the overall position
of NSW cancer services
and current practice in
your clinical field
Please detail how many
hours a month you

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expect to commit to
support this initiative


C.3 Evidence of prior mentoring/ supervision of cancer nurses/allied health
staff
Please describe your experience in supervising/mentoring/coaching staff in the past 5 years
i.e. number of staff, role capacity etc




C.4        Research support
List how the research will be supported throughout the 12 month timeframe. In the table
below please provide details about roles of co-investigators, and others providing data
support, mentoring, or equipment support.

 Support role               Name            Facility / Institution     Expected contribution
                                                                           to proposal
Co-investigator 1

Co-investigator 2

Statistical
support

Mentoring
/coaching

Other
(please specify)



C.5        Learning program
Identify and list the skill /knowledge expansion that you expect to be gained by the applicant
Skill                         Name and Short description
Skill 1:


Skill 2:


Skill 3:


Skill 4:


How will completing

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the proposed research
contribute to the
applicant’s clinical or
research pathway in
oncology or palliative
care?

Any additional
supporting comments?




SECTION D – BUDGET
This section should be completed by the supervi sor in relation to the proposed clinical
research program to be undertaken

D.1 Budget Breakdown
This section should be completed by the supervisor in relation to the proposed
clinical research program to be undertaken. Budget items must be justified in terms of need
and cost in respect to the research plan and completed in the form below.

              Item               Amount in $                      Justification
 1.Salary                        $
 (Please fill in Award & Level
 details below eg NUM yr 3)

 Award__________________

 2. On-costs
 Workers comp
 Superannuation
 Other ( please give details )

 3. Other
 ( please give details of need
 and cost in respect to the
 research plan)

 4. Institutional budget                       Please give details of costs your organisation will be
 contribution                                  meeting in respect to the research plan
                                               e.g. IT, software, workstation, equipment, training

 TOTAL requested
 excluding GST and item
 4 above




SECTION E – CANCER SERVICE / INSTITUTION DETAILS

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E.1.     Institution and Department where the clinical research will occur.
Name and full address of the AHS and cancer service/s or locations in which the clinical
research will be undertaken.

Cancer Service/s:



Address:




SECTION F – CERTIFICATIONS
Privacy Notice
Applicants 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 and relevant representatives of the
Cancer Institute NSW. 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.


F.1      Certification by Lead Supervisor
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. For nominated applicants at the time of application, I certify that the salary outlined in the
Budget Section is the correct remuneration package for the applicant in line with current
employment awards.
3. I consent to this application being peer-reviewed by persons who will remain anonymous.
4. I have read and agreed to the Privacy Notice above.

 Lead supervisor signature                           Name                     Date




I.2      Certification by Administering Institution

 Institution

 ABN

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Administering Institution contact person for management of the grant and
funding
Please provide details of the nominee from the Finance Department below.

 Name

 Title

 Cancer
 Service

 Address

 Email

 Phone no.

I certify that:
1. I am authorised to sign the application form on behalf of this Administering Institution.
2. I am prepared to have the Cancer Institute NSW funded clinical research carried out in this
institution/ organisation under the circumstances detailed in this application.

3. All funds for the proposed clinical research will only be spent for the purposes for which
they were provided.

3. The proposed applicant will remain employed at the institution for the duration of the
Clinical Research Grant and will be available to commence January 2009.

 Name

 Title

 Facility

 Signature

 Date



I.3      Certification by Director of Area Cancer Services (DACS)

Certification by the DACS
I certify that:
1. I am authorised to sign the application form on behalf of this cancer service.
2. 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.
3. The applicant’s clinical load will be reduced to 0.5 FTE and this will be maintained for the
  12 month period to facilitate them undertaking the proposed research work beginning in
  January /February 2009 /or a 0.5 project officer has been recruited to conduct the work

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   under the supervision of the applicant (cross out which does not apply.)
5. The applicant will be provided with a professional workspace within the general facilities of
   this institution/ organisation, and appropriate IT infrastructure/support is available.
6. Any necessary appropriate ethics clearance(s) have been obtained.
7. The applicant will be provided with ongoing supervision and support during the 12 month
   timeframe.

 Name

 Title

 Signature

 Date



I.4      Certification by the Chief Executive

Certification by the CE
I certify that:
 I have read this application and fully support the clinical research proposed being
undertaking in the Area Health Service in accordance with this application.

 Name

 Title

 Signature

 Date




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G - APPLICATION CHECKLIST

The following checklist should be followed to assist you in completing your submission.
Incomplete applications will not be accepted.

1     Applicant Two page CV is attached

2     Evidence of Australian citizenship/residency status during timeframe of the
      clinical research is attached
3     Evidence of masters qualifications/or equivalent is attached

4     All certification signatures are signed and dated
            Applicant
            Lead Supervisor
            DACS
            Chief Executive

5     Supervisor’s six page CV is attached

6     Referee reports - have been provided

7     Electronic copy of Application provided to Secretariat (by email or via a CD)

8     Required copies provided (1 original plus 10 copies), double sided




Please send applications in hard copy, including all attachments, to:

Via courier:                                                 Via post:
Attention: Emma Niccol                          OR           Attention: Emma Niccol
Cancer Services & Education                                  Cancer Services & Education
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

Electronic copies may be emailed to emma.niccol@cancerinstitute.org.au




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APPENDIX 1:              Clinical Research Grant 2009 (Nursing and Allied Health

            GUIDELINES FOR COMPLETION OF REFEREE REPORT FORM

Cancer Institute NSW Clinical Research Grants provide a year where senior cancer
nurses and senior allied health clinicians can enhance their research and evidence-
base practice skills and expertise on a part time basis. The program’s objectives are
to:

1.       Provide an opportunity for recipients to further develop their clinical practice and
         research skills linked to their current clinical nursing or allied health practice;
2.       Encourage the development of long-term nursing or allied health career development
         pathways in the cancer workforce in NSW;
3.       Facilitate the translation of new procedures, techniques and treatments, or new
         research outcomes into allied health/nursing practice settings;
4.       Contribute evidence-based nursing and allied health clinical practice and the use of
         multi-disciplinary care to the body of cancer related knowledge;
5.       Support job satisfaction and the retention of the cancer nursing and allied health
         cancer workforce in NSW;
6.       Contribute to the development of world’s best nursing and allied health cancer clinical
         practices in NSW.


Would you please comment in more detail as appropriate about:
    your overall assessment of the applicant’s research experience and abilities;
    your assessment of academic performance (including their published work and work
     published in cooperation with others);
    your view of their current role and future prospects as a senior cancer clinician;
    your view on the quality of the research proposal; and

    any other comments that you consider relevant to the application.

The form follows.




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                           REFEREE REPORT – IN CONFIDENCE

Applicant to complet e Section A details and forward the form to the nominated referee

Section A:        Applicant’s details
Title

Given names

Family name

Research title

Section B         Referee details

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


Signature
Date


Report (Maximum 2 pages)




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Please send the typed report to the Cancer Institute NSW by email to:

emma.niccol@cancer.institute.org.au

or by fax to 02 8374 5778 no later than 25 June 2008.

Please send original documents to:


Attention: Emma Niccol                       OR             Attention: Emma Niccol
Cancer Services & Education                                 Cancer Services & Education
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




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