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NMRC_Fellowship_Application_Form

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NMRC_Fellowship_Application_Form Powered By Docstoc
					RESEARCH TRAINING
FELLOWSHIP APPLICATION

1. Please read the instructions carefully and fill in all the sections.   Indicate “N.A.” if not
   applicable.

2. Together with this application form, an application package must include the supporting
   documents listed below. Please use the checklist below for your easy reference to ensure that
   your application is complete.
   Documents:
        Copy of Singapore National Registration Identity Card.
        Letter of appointment/employment contract and information on your remuneration
        package (e.g., salary, annual wage supplement, bonus).
        Details of Research Project under the following headings: Introduction, Aims,
        Hypotheses, Methodology and References.
        Information on optional/mandatory courses to be taken, if applicable.
        Document(s) detailing fee structure for PhD or Master’s training (if applicable).
        Declaration by OHR (ANNEX I).
   Letters from:
        CMB - Written commitment that the fellow will have a minimum of 30% protected time
        for research upon the fellow’s return from his/her training.
        HOD - Letter of recommendation that includes Department’s commitment to provide
        continuing oversight for the fellow’s training.
        Research Supervisor (during period of award) - Letter of undertaking and curriculum
        vitae (to include a record of research funding & a record of past and current fellows
        trained.)
        Research Mentor (after period of award) - Letter indicating commitment to mentor
        fellow upon fellow’s completion of the training award and curriculum vitae (to include a
        record of research funding & a record of past and current fellows trained.)

3. Please submit your application to:
       The Executive Director
       National Medical Research Council
       11 Biopolis Way, Helios, #09-10/11
       Singapore 138667

[All information is treated in confidence. The information is furnished to the National Medical
Research Council with the understanding that it will be used for evaluation, reference and
reporting purposes only.]

Types of Training:

     Full-time local post-graduate training          Part-time local post-graduate training
     (PhD/MSc/MPH/____ )*                            (PhD/MSc/MPH/____ )*

     Full-time overseas research attachment          Part-time overseas research attachment
     leading to a graduate degree                    leading to a graduate degree
     (PhD/MSc/MPH/____ )*                            (PhD/MSc/MPH/____ )*

     Full-time overseas research attachment
     not leading to a degree

(*Please indicate the type of Degree.)




                                              -1-
1. PERSONAL PARTICULARS
Name of Applicant (as in the NRIC)

Surname:                                           Given Name:
Date of Birth:    Place of Birth:
                                                    Male                 Married
(dd/mm/yyyy)
                                                    Female            Single
Nationality:      NRIC No.:                      If non-Singaporean, please indicate date
                                                 granted PR status: (dd/mm/yyyy)

Home Address:                                    Mailing Address:




Email Address:


Contact Numbers

Home:                   Office:                      Hp:                       Fax:
Qualifications: (Academic & Professional)




Academic Grade: (E.g., Assistant Professor, Associate Professor, Professor)



Clinical Grade: (E.g., Medical Officer, Registrar, Associate Consultant, Consultant, Senior
Consultant)




2. PROPOSED RESEARCH PROJECT
(i) Research Project Title:



(ii) Key words:


Please provide a maximum of 6 key words related to the research project.
 (iii) Abstract:
Between 200 to 300 words, please describe the aims, hypotheses, methodology and approach of
the research proposal.



 (iv) Detailed Research Proposal:
 Please also attach details of the research project, including:
     Introduction
     Aims
     Hypotheses
     Methodology
The above should be in presented in no longer than 10 pages. References should be attached at
the end of the proposal and does not count towards the page limit. Please present the research
proposal on A4-sized paper, 1-inched margins, single-line spacing and size 12 Times New Roman
font.




                                             -2-
(v) Field of Research / Health Category:
Please select up to 5 categories from the following.

Blood                                           Musculoskeletal
Cancer                                          Neurological
Cardiovascular                                  Oral and Gastrointestinal
Congenital Disorders                            Renal and Urogenital
Ear                                             Reproductive Health and Childbirth
Eye                                             Respiratory
Infection                                       Skin
Inflammatory and Immune System                  Stroke
Injuries and Accidents                          Generic Health Relevance
Metabolic and Endocrine                         Other : _________________________


A) PLACE OF RESEARCH TRAINING
 Department:                             Institution:


Address:


Duration of Research Training: ___ month(s)

Start Date: (dd/mm/yyyy)     Completion Date: (dd/mm/yyyy)
B) RESEARCH SUPERVISOR DURING AWARD
Name:                         Email:


Designation:                             Phone:


Department:                              Institution:



Field of Research / Health Category: [To indicate only if different from section 2(v)]
Please select up to 5 categories from the following.

Blood                                           Musculoskeletal
Cancer                                          Neurological
Cardiovascular                                  Oral and Gastrointestinal
Congenital Disorders                            Renal and Urogenital
Ear                                             Reproductive Health and Childbirth
Eye                                             Respiratory
Infection                                       Skin
Inflammatory and Immune System                  Stroke
Injuries and Accidents                          Generic Health Relevance
Metabolic and Endocrine                         Other : _________________________


Please attach the following:
   Letter of undertaking from the proposed Research Supervisor
   CV [to include details of current and pending funding; i.e. name of agency, number of grants
    held, grant title, role (e.g. PI or co-PI), grant duration and the awarded budget]
   Training record of the Research Supervisor (e.g., number of fellows previously trained and
    number of fellows currently in training)
C) RESEARCH MENTOR (LOCAL) AFTER AWARD PERIOD
Name:                                          Email:


Designation:                               Phone:




                                             -3-
Department:                              Institution:



Field of Research / Health Category: [To indicate only if different from section 2(v)]
Please select up to 5 categories from the following.

Blood                                         Musculoskeletal
Cancer                                        Neurological
Cardiovascular                                Oral and Gastrointestinal
Congenital Disorders                          Renal and Urogenital
Ear                                           Reproductive Health and Childbirth
Eye                                           Respiratory
Infection                                     Skin
Inflammatory and Immune System                Stroke
Injuries and Accidents                        Generic Health Relevance
Metabolic and Endocrine                       Other : _________________________


Please attach the following:
   Letter of undertaking from the proposed Research Mentor
   CV [to include details of current and pending funding; i.e. name of agency, number of grants
    held, grant title, role (e.g. PI or co-PI), grant duration and the awarded budget]
   Training record of the Research Mentor (e.g., number of fellows previously trained and
    number of fellows currently in training)




                                           -4-
3. EMPLOYMENT INFORMATION OF APPLICANT
Institution / Department


Address of Employer


HR Contact Person

Name                                               Tel. No.

Designation
Employment History
    Institution /              Appointment                Date From           Date To
    Department                                          (dd/mm/yyyy)       (dd/mm/yyyy)




(Please attach a letter of recommendation from Head of Department, your appointment letter /
employment contract and latest information on your remuneration package.)


4. SCHOLARSHIPS/AWARDS
                                       Date
   Scholarship/Award           From            To                  Funding Body
                            (dd/mm/yy)     (dd/mm/yy)




                                         -5-
5. COURSES/SEMINARS/CONFERENCES ATTENDED IN THE LAST 3 YEARS




6. PUBLICATIONS




                              -6-
7. DECLARATION BY APPLICANT
Please provide the following information:

Are you currently receiving any fellowship/training award?
          No               Yes. Please specify:

Have you applied for funding from other agencies for the proposed training?
          No              Yes. Please specify:

During the proposed training period,
a) will you be accompanied by your spouse who is a recipient of an HMDP Fellowship or other
   training award?
           No             Yes. Please provide the name of your spouse, training award and
                                 training period:

b)    will you be receiving any income from your current employer                and/or   any   other
     hospital/institution in Singapore?
             No                Yes. Please state the source(s) and the amount:

c) will you be receiving any stipend from other source(s) (e.g., the institution where you will be
   training as a NMRC Fellow and/or any funding body outside Singapore)?
            No             Yes. Please state the source(s) and the amount:



Please tick the items required for funding under the NMRC Research Training Fellowship:
(Office of Human Resource to provide the estimated amount claimable in Annex I. Funding will be
in accordance with the host institution’s policy.)
     Salary                                               Tuition fees
     Maintenance allowance                                Insurance

     Airfare(s)                                           Conference(s)

     Others (Please specify and justify):




I DECLARE that, to the best of my knowledge, the information I have provided on this form is true,
accurate and complete.

I consent to the NMRC holding and using the data on this application form together with other
documents attached for the purpose of administering and reviewing my fellowship application. I
agree that such data may be made available to those who reasonably need to know within the
NMRC and NMRC-appointed reviewers.




___________________________________                                       ______________________
      Signature of Applicant                                                  Date (dd/mm/yyyy)




                                              -7-
8. ENDORSEMENT BY HEAD OF DEPARTMENT

A) INSTITUTIONAL SUPPORT UPON THE COMPLETION OF TRAINING
To be completed by HOD/Nominee. Please indicate the means by which the institution will support
the returning fellow by ticking the appropriate box(es).

                                                                     Please provide details

     Seed money for research grant
     (State the amount and source of seed funds)                ______________________________

     Availability of lab space
     (Specify location of lab space and the area in             ______________________________
     square metres assigned to the fellow.)

     Clinical position secured for the fellow for the first 3
     years after his/her return.                                ______________________________
     (Please specify.)

     Salary support & protected time (should be aligned
     with the written commitment from CMB) as stated            ______________________________
     on Page 1, Point 2 of the application form.

     Specify access to facilities & equipment                   ______________________________

     Technical manpower support                                 ______________________________

     Collaboration opportunities                                ______________________________
     (Name collaborators)

     Others                                                     ______________________________
     (Please specify.)



I support the above application for the NMRC Research Training Fellowship. The Institution will
protect the fellow’s time; provide him/her with the necessary support, facilities and equipment as
specified above upon completion of his/her research training to enable him/her to continue his/her
development in clinical/biomedical research.




___________________________________                                      ______________________
      Signature of Head of Dept                                                    Date

Name:


9. ENDORSEMENT BY THE INSTITUTION / MEDICAL SCHOOL

I support the above application for the NMRC Research Training Fellowship. The Institution will
protect the fellow’s time; provide him/her with the necessary support, facilities and equipment as
specified in section 8 upon completion of his/her research training to enable him/her to continue
his/her development in clinical/biomedical research.




___________________________________                                      ______________________
Signature of Director/CEO of Institution                                           Date
     OR Dean of Medical School*

Name:
* Please delete where appropriate



                                                -8-
ANNEX I: [FOR INSTITUTION HR’S USE ONLY] Breakdown of Fund Required for
the NMRC Fellowship.
(Office of Human Resource to provide the estimated amount claimable in ANNEX I. Funding must
be in accordance with the host institution’s policy. Fund request should not be more than
S$500,000.)


Items                                                                              Amt ($)

  Salary
  Maintenance allowance

  Airfare(s)

  Tuition fees

  Insurance

  Conference(s)

  Others (please specify)




                                                              Funding estimates provided by:


                                                            ________________________
                                                                 Signature of HR Officer

                                                                                Name:
                                                                          Designation:
                                                                   Date: (dd/mm/yyyy)




                                         -9-

				
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