phd scholarships application form - web viewepidemiology, bioinformatics ... information provided in...

Application FormPhD Scholarships

Deadline: 5pm, 21 February 2017

Please save using the following format for naming: PhD Candidate Surname_ Candidate First Name (e.g. PhD_ Cohen_John)

To be submitted by the Host Organisation on behalf of the Applicant

Section A – Administrative Overview

A1. Candidate details

Title

Last Name

Phone number

Are you an Australian Citizen/Permanent Resident? YES NO**Non Australian Citizens/Non-Permanent Residents are not eligible to apply.

Identify a single key PhD Scholarship priority area that will be developed through the scholarship. The PhD Scholarship priority areas are: epidemiology, bioinformatics, health economics and biostatistics, implementation science, health systems research, health workforce, and ‘omics. For the priority area mentioned, please ensure your Skills Development Plan (D1) illustrates how this area will be developed.To nominate a different area for development, please provide a justification for the local, regional or State-wide demand at C3.4.

Are you already enrolled and are an existing PhD student? YES NO

If yes, what was your date of commencement? ______month ________year

If yes, how many full-time or part-time equivalent years of the PhD program will have been completed by the Semester 2 commencement date? _________ years

Are you applying for a part time Scholarship (< 35 hours per week)? YES NO If yes what is your student load (e.g. 50% of full time) _______ and;

In what month and year do you anticipate you completing your PhD? _______ (month) _______ (year)

Has the Host University approved enrolment on a part time basis? YES NO

Please attached evidence of this approval (e.g. copy of Letter of Offer)

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Office use only

Application ID #:

First Name

Email address

Are you the holder of an existing scholarship (or are about to start one)? YES NO

If yes, what is the name of the scholarship?

If successful in obtaining a NSW Health PhD Scholarship, do you agree to relinquish this other scholarship? YES NO

A2. Host Organisation details

Name

Address

Proof of

Enrolment

Primary Academic Supervisor Name & TitlePlease attach Academic Supervisor CV of no more than 5 pages

A3. Health Practitioner/Policy Supervisor detailsPlease attach Health Practitioner/Policy Supervisor CV of no more than 5 pages (only if different from primary Academic Supervisor in A2).

Full Name

Position

Organisation Name

Address

Phone number

Section B – Candidate Information provided in this section will be used to assess the application against Eligibility and Selection Criteria published in the Program Guidelines.

B1. Academic and relevant professional qualificationsOnly enter one (1) qualification per field, please add a new row for each additional qualification.# Degree/Award Year Organisation and Country

1Add

B2. Research, clinical and industry experience and work in multidisciplinary teamsPlease list all current and previous research, clinical and industry appointment(s)/position(s) held during the past ten (10) years. Please only enter one (1) position per field, and add a new row for each additional position.# Position Held Organisation Other Disciplines* Engaged

with for this RoleYear Started - Year Ended / ‘Ongoing’

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Email address

1Add

*Other disciplines could include: specific health professions such as nurses; researchers with different and complementary expertise such as bioinformaticians and health economists; and other professions such as engineers, scientists, health administrators and policy makers.

B2. Track record in research, relative to opportunityJournal ArticlesPlease list your top career journal articles relevant to the proposed research project, add a new row for each additional example (maximum 10). # Full Reference (including Year of

Publication)Peer Reviewed (yes/no)

Order of Author (e.g. 1st Author)

Impact Factor of Journal

No. Citations

1

Add Books, reports and patentsPlease list your top outputs relevant to the proposed research project, add a new row for each additional example (maximum 10).# Full Reference Type (e.g. Book, Chapter, Report or

Patent)Year of Pub

1

Add

ConferencesPlease list your top conference presentations including poster presentations, relevant to the proposed research project, add a new row for each additional example (maximum 10).# Full Reference Year Location Presenting Author(s)1

Add

Funding Awarded (last 5 years only)Please list funding awarded to current and past projects from 2011 onwards, add a new row for each additional example.# Grant Title Chief

InvestigatorsFunding Source

Grant Type (e.g. Project)

Total Grant Amount

Years Covered by Grant (e.g. 2012-2014)

1

Add

Responsibilities impacting on track recordFor the previous ten (10) years, please note any significant career disruptions or clinical responsibilities that could reasonably be considered to have had a negative impact on your research track record (maximum 150 words).

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Section C – The Skills Development PlanSections C3.1, C3.2, C3.3 and C3.4 together constitute the Skills Development Plan for the candidate. They will be used to assess the application against the Selection Criteria (especially Selection Criteria 1 – Skills Development Plan as outlined in the Program Guidelines).

C3.1 Existing SkillsPlease describe (maximum 600 words) your existing skills and experience that are directly related to the topic area(s) and/or methodology of the research proposal. This description may also describe how your existing experience links to your nominated priority area for development.

C3.2 Strategy for Skill Learning and Development in the Nominated Priority Area Please describe (maximum 600 words) the nominated priority area for your skills development and how the skill development will occur (the Strategy). This must also include how skills development is related to the topic area(s) and/or methodology of the research proposal. You may also include information on the benefit to any post PhD endeavours and/or career paths. This description should clearly outline the milestones for when stages of the skills development are expected to be achieved (e.g. in Year 1, 2 or 3).

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C3.3. Capacity of Host Organisation and Partner Organisation to provide career support and mentoring to the CandidatePlease describe (maximum 600 words) any career support and or mentoring in place by the Host University and the Partner Organisation to support the candidate over the course of the Scholarship. This description should highlight where this support and mentoring is relevant to the Candidate’s PhD, post PhD endeavours and nominated PhD Scholarship skills priority area; and if and how any other partner or external organisations are to be engaged in this process. This may include partnering with an identified centre for excellence in a relevant PhD Scholarship priority area.

C3.4 Justification of non-priority skill area (optional)If the nominated skills to be developed in C3.2 are not from the priority areas then a justification as to why they are needed in NSW can be included here. Reference should be made to strategies, reports, or other materials that support the case for inclusion. (Maximum of 400 words)

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Section D – Partner OrganisationInformation provided in this section will be used to assess the application against the eligibility and selection criteria.

D1. Evidence of Support from Partner Organisation Please attach documentation and evidence (emails, letters etc.) of the support of health and medical

research leaders at the Partner Organisation. This may also outline any financial support or other support (e.g. mentoring, access to infrastructure, etc.) that the leader/s of the Partner Organisation chooses to highlight.

D2. Appropriately qualified Health Practitioner/Policy Supervisor Please describe (maximum 400 words) the nominated Health Practitioner/Policy Supervisor’s relevant qualifications and experience. This description should highlight how these qualifications and experience are relevant to the candidate’s PhD and nominated PhD Scholarship priority area for development.

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Section E – Research Proposal Information provided in this section will be used to assess the application against selection criteria 2.

E1. Outline of proposed research project including purpose and objectivesPlease describe (maximum 400 words) the proposed research project, including its purpose and objectives.

E2. Proposed methodologyPlease describe (maximum 600 words) the methodology to be used.

E3. Project timelinePlease provide a list of key project milestones and deliverables with an indication of when each should be completed, add a new row for each additional Milestone.# Key Project Milestone Related Deliverables Completion

Date1

Add

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E4. Knowledge translation planKnowledge translation is relevant to a PhD research project; from knowledge and expertise that informs the planning and development of the project; to dissemination of findings to relevant audiences; and ultimately the implementation of findings in policy and practice. Effective knowledge translation helps to ensure population and practice relevant research findings are disseminated, and includes building relationships and engagement with other researchers, clinicians, the public, and policy makers.

Please provide specific examples of activities to support the translation of knowledge from the research project into policy and/ or practice. Each example should include who will be engaged, when, and how, as well as the intended impact of each engagement and how it will support successful implementation. Add a new row for each additional activity.

# Engagement & Dissemination

Activity/ Method

Organisation, Group or Individual to be

Engaged

Timing and Purpose of Engagement

Intended Impact of this Engagement on Implementation

1 Types of activity include: meetings with

individual stakeholders

telephone or face-to-face interviews

focus groups inclusion of

stakeholders in project governance structures

surveys publication of

findings on open access platforms

dissemination workshops

Groups include: patients or ‘end

users’ clinicians policy makers researchers health service

managers patient advocacy

groups industry peak organisations

Including: at the initial planning

phase to help define the problem and develop policy and practice relevant research questions

during the research activity to identify potential implications and applications of the research and its findings

when disseminating the initial findings to support the scaling up of the research findings and implementation in practice

Including: to improve the

relevance of the research and its findings to practice for more effective implementation

to support the scaling up of research findings

to ensure research findings are translated into policy and clinical practice

Add

E5. Post PhD PartnershipsPlease list and describe (maximum 400 words) any post PhD Scholarship partnerships/relationships that the candidate will develop throughout the PhD, their importance and how they will be cultivated.

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E6. Lay SummaryPlease provide a lay summary of the proposed research project for inclusion in future communications on the research projects receiving support through NSW Health PhD Scholarship Program (maximum 400 words). This summary should incorporate key information provided in response to questions in Section E of the application form and:

Provide a clear and succinct description of the purpose of the research Avoid overly technical language and explain key terms Explain the value and relevance of the research to individuals, specific populations and policy Highlight any novel methods or technologies being used Describe how research findings will be translated into policy and practice, including any examples of

engagement with the public, patients and clinicians.

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Section F - DeclarationsF1. Declaration by the CandidateI 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 will render me ineligible for PhD Scholarship funding.

2. I have negotiated supervision from an appropriately qualified employee of an eligible NSW Host University for the term of the Scholarship (A3).

3. I consent to this application being submitted on my behalf by the Host University4. I consent to this application being shared with expert reviewers engaged in the selection process.

Full name

Signature Date

F2. Declaration by the Host University

I certify that:1. I am an authorised signatory on behalf of the entity identified as the Candidate’s Host University.2. The candidate has an agreement with this University to undertake the research described in this

application as a PhD candidate of this University.3. This University is prepared to provide any support to the named Academic Supervisor that is necessary to

supervise and mentor the candidate during the term of the Scholarship. 4. This University is prepared to meet all standard employer responsibilities required by law, and

accommodate and support the candidate for the term of their scholarship (including the provision of infrastructure such as office space, computer etc.).

5. This University’s policies and practice support gender equity.6. This University will contribute $20,000 per annum towards the PhD Scholarship as a stipend and

excluding tuition costs OR has a guarantee from a Partner Organisation that they will contribute $20,000 per annum as a stipend and excluding tuition costs

7. This University is committed to including the candidate in relevant project grants.

Full name & Position

Signature Date

F3. Declaration by the Partner Organisation

I certify that:1. I am an authorised signatory on behalf of the entity identified as the Candidate’s Partner Organisation.2. The candidate has an agreement with this organisation to undertake the research described in this

application.3. This organisation is prepared to provide any support to the named Health Practitioner/Policy Supervisor

that is necessary to supervise and mentor the candidate during the term of the Scholarship.4. This organisation is engaged in the delivery of health and medical research and can be classified as: a

department or research centre within a University; a NSW Health entity; an independent Medical Research Institute; or a not-for-profit organisation.

5. This organisation’s policies and practice support gender equity.6. This organisation is committed to including the candidate in relevant research projects.


Signature Date

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F4. Declaration by Health Practitioner/Policy Supervisor

I certify that:1. To the best of my knowledge and belief, information contained in this application is complete, true and

correct.2. I have agreed to act as a Health Practitioner/Policy Supervisor for the duration of the candidate’s

Scholarship, and provide support in line with the principles set out in the application Guidelines and in this Application.


Signature

Date

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Section G. Additional Information On The Candidate

(to be completed by the Candidate)G1. Are you of Aboriginal or Torres Strait Islander origin?

☐No

☐Yes, Aboriginal

☐Yes, Torres Strait Islander

☐Yes, both Aboriginal and Torres Strait Islander

☐Prefer not to say

G2. Please indicate your gender (for the purposes of monitoring this scheme)

☐Male

☐Female


G3. Are you from a Rural or Remote location? (i.e. ordinarily study and reside outside the Sydney Metropolitan Area) (for information only)

☐No

☐Yes


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Section H. Instructions For Submission Of Application

PLEASE NOTE: Late or incomplete applications will be deemed ineligible

A representative of each Host University must submit all documents related to this Application to the PhD Scholarships email ([email protected]) by 5pm, 21 February 2017.

This should include: Completed Application form, as a Word document Scanned copy of the signed declarations (PDF) Host Organisation’s Letter of Offer/ Proof of Enrolment into PhD (PDF) Academic Supervisor’s CV Health Practitioner/Policy Supervisor’s CV (PDF) Evidence of Support from Partner Organisation if applicable - certified evidence of residency status and the right to remain in Australia for the duration

of the funding period (PDF)

Your application must be saved using the following format for naming and in the email subject line:PhD Candidate Surname_ Candidate First Name (e.g. PhD_ Cohen_John)

For each additional attachment please use the following format for naming: PhD Candidate Surname_ Candidate First Name_document name (e.g. PhD_ Cohen_John _Academic Supervisor CV)

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mailto:[email protected]

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