Application Form. UWA Research Group Based Fellowships. UWA School Seeding Fellowships

Transcription

1 Our ref: Faculty of Medicine, Dentistry & Health Sciences (M501) Application Form UWA Research Group Based Fellowships UWA School Seeding Fellowships Closing date First Friday in July each year LATE OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED CRICOS Provider Number: 00126G L:\Student administration\scholarships\medical Awards\Forms and advice

2 IN CONFIDENCE: * Please refer to instructions 1 Full Name of Applicant Title Surname Given Names 2 Application for: UWA RESEARCH GROUP BASED FELLOWSHIP UWA SCHOOL SEEDING FELLOWSHIP 3 Have you applied for Fellowship support from other funding agencies (eg NHMRC Australian Biomedical (Peter Doherty) Fellowships, Australian Clinical Research Postdoctoral Fellowships, Raine or Ramaciotti Foundations, etc.)? If Yes, please indicate in the space provided which fellowships. Gender (M/F) Enter Y/N Enter Y/N Enter Y/N If No, you may not be eligible for these Awards (see Guide to Applicants Item 3) 4 Current Appointment 5 Date of Appointment (Format DD MON YYYY) 6 Full Postal Address for Notification (Please advise immediately of any changes to this address) Telephone (including mobile) ( ) Facsimile ( ) 7 SCHOOL WITHIN UWA WHERE PROJECT WILL BE CARRIED OUT 8 NAME OF SUPERVISOR OF RESEARCH PROJECT 9 SCIENTIFIC PROJECT TITLE (Maximum 90 Characters including spaces) 10 SIMPLIFIED PROJECT TITLE (Maximum 90 Characters including spaces) 2 UWA Medical Awards

3 11 Undergraduate Academic Qualifications (Attach academic transcripts). Year Grade/Honours Institution where degree awarded 12 Awards, Scholarships or Prizes 13 Postgraduate Qualifications PhD Studies Title of PhD Supervisor School/Discipline Date PhD was Classified as Passed (Please attach notification letter) (Format DD MON YYYY) Date Corrections complete and thesis submitted for permanent binding (Format DD MON YYYY) 14 Career Summary (include relevant positions, further training and Grants or Fellowships held) Year Positions held or Study Institution L:\Student administration\scholarships\medical Awards\Forms and advice

4 15 Publications of Applicant for Consideration of Track Record Please ensure that you list only those papers, articles or abstracts that have been published in refereed journals in the last six years (indicate clearly whether published or in press and include evidence of final acceptance by the editor). Include reviews, book chapters and conference presentations. 4 UWA Medical Awards

5 16 Research Plan - Aims, Background and Significance. Please provide a proposal including the aims, background and significance of your Proposed Research Program, (briefly mention proposed technologies), a statement concerning the significance of the proposal and References (a few critical journal references only, no titles). Please do not exceed the two pages provided for this purpose. L:\Student administration\scholarships\medical Awards\Forms and advice

6 Research Plan, Aims, Background and Significance Continued 6 UWA Medical Awards

7 17 Justification of Project in relation to the fellowship describe how your career would benefit the School, commitment to Medical or Dental Research in Western Australia and the Faculty of Medicine, Dentistry and Health Sciences. L:\Student administration\scholarships\medical Awards\Forms and advice

8 18 Referee Reports In-Confidence (applicant nominated) First Referee Name Address Postcode Telephone Number ( ) Facsimile ( ) Second Referee Name Address Postcode Telephone ( ) Facsimile ( ) Third Referee Name Address Postcode Telephone ( ) Facsimile ( ) 8 UWA Medical Awards

9 19 Certification by Applicant, Head of Proposed School and Supervisor Signature of Applicant In signing this page, I certify that all details given in this application are correct and I agree to carry out the Fellowship in strict accordance with the current Regulations governing UWA Medical and Dental Research Awards Signature of Applicant Date Signature of Head of School I certify that should... be awarded a UWA Medical Research Fellowship, this School will provide appropriate facilities and the project will be carried out strictly in accordance with the Regulations governing UWA Medical and Dental Research Fellowships. Name (Please Use Block Letters) Title Name Department Institution Signature of Head of Proposed School 20 Certification by Proposed Supervisor Date I certify that should... be awarded a UWA Medical or Dental Research Fellowship, I will be willing to supervise the applicant and provide assurance that any ethics clearances will be obtained and the necessary facilities to carry out the project are available. Name (Please Use Block Letters) Title Given names Surname Appointment Department Institution Signature of Proposed Supervisor Date L:\Student administration\scholarships\medical Awards\Forms and advice

10 21 Clearance Requirements Does this project include: (a) Research Involving Humans? (b) Experiments on Animals? (c) Other Clearances If Yes, does your School hold a signed statement indicating your awareness of the Guidelines for Laboratory Personnel Working with Carcinogenic or Highly Toxic Chemicals? Enter Yes or No Enter Yes or No Enter Yes or No Enter Yes or No Please Note: This project cannot proceed until ethics clearances have be obtained (d) Ethical Implications of the Project Experiments on Animals/involving Humans Checklist Applicant School Project Title Application form (one single-sided hard copy & ten double-sided hard copies) Notification of Award of PhD (as appropriate) Academic transcripts Certification by Head of School and Supervisor Completion of all Sections Yes No 10 UWA Medical Awards

11 Applicant s Details Name: Faculty of Medicine, Dentistry and Health Sciences The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Mailbag: M501 Current Institution: Project Title: REFEREE REPORT - Closing date First Friday in July each year Overseas Biomedical Research Fellow Overseas Clinical Research Fellow UWA Postdoctoral Research Group Based UWA Postdoctoral School Research Seeding Please provide an overall judgement supported by details comments similar to a report for an applicant seeking a University appointment. The following points are provided as a guide: 1. Has the candidate shown an originality of approach in his/her published work? Please comment on the standing of the journals in which the applicant s work has appeared. 2. Has the applicant received outside recognition for his/her work other than normal appointments to postdoctoral fellowships and the like? 3. Comment on the importance of the applicant s work and his/her standing in the international field. 4. Please comment on the potential benefit of the proposed project to the future career development of the applicant and if possible indicate how the applicant s ability and personal qualities rate in comparison with other researchers. H L:\Student administration\scholarships\medical Awards\Forms and advice

12 Referee Details Name: Appointment: Institution Signature Date Please ensure that the completed report reaches the: Administrative Officer (Student Affairs), Fellowships and Scholarships, Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Mailbag: M501 This report can be faxed or ed to: Fax: (08) UWA Medical Awards

13 Applicant s Details Faculty of Medicine, Dentistry and Health Sciences The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Mailbag: M501 Name: Current Institution: Project Title: REFEREE REPORT - Closing date First Friday in July each year Overseas Biomedical Research Fellow Overseas Clinical Research Fellow UWA Postdoctoral Research Group Based UWA Postdoctoral School Research Seeding Please provide an overall judgement supported by details comments similar to a report for an applicant seeking a University appointment. The following points are provided as a guide: 1. Has the candidate shown an originality of approach in his/her published work? Please comment on the standing of the journals in which the applicant s work has appeared. 2. Has the applicant received outside recognition for his/her work other than normal appointments to postdoctoral fellowships and the like? 3. Comment on the importance of the applicant s work and his/her standing in the international field. 4. Please comment on the potential benefit of the proposed project to the future career development of the applicant and if possible indicate how the applicant s ability and personal qualities rate in comparison with other researchers. H L:\Student administration\scholarships\medical Awards\Forms and advice

14 Referee Details Name: Appointment: Institution Signature Date Please ensure that the completed report reaches the: Administrative Officer (Student Affairs), Fellowships and Scholarships, Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009 Mailbag: M501 This report can be faxed or ed to: Fax: (08) UWA Medical Awards