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WCH FOUNDATION
2018 MATTHEW SCRIVERPICU NURSES SCHOLARSHIP
APPLICATION FORM Application1. PERSONAL DETAILSNAME:Title / First Name /Surname
2. CONTACT DETAILSPostal/Delivery Address:(incl. floor / level / building)
Department / Division:
Telephone (work): Mobile:
Email:
3. CURRICULUM VITAE (short Personal CV – to be included as an attachment to this application)This should include (amongst other relevant info):3.1 Education3.2 Employment history3.3 Awards3.4 Research experience – Include completed research projects, research grant achievement and brief
summary of research projects3.5 Publications3.6 Presentations
4. OUTLINE OF RESEARCH PROJECT 4.1 TITLE OF THE RESEARCH PROJECT
4.2 NAME OF DEPARTMENT (WCHN department in which the research work will be undertaken)
4.3 ABSTRACT OF THE RESEARCH PROJECT: in lay terms (300 words or less)
4.4 BRIEF DESCRIPTION OF THE RESEARCH PROJECTNB: (4 pages or less), should include research objectives, recruitment and consent (if applicable), research methods, data analysis and interpretation techniques, the significance of the study for paediatric health care in a PICU setting.
4.5 PROJECT FINDINGSOutline where and in what format the applicant is aiming to publish and/or present the project findings
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5. NAME OF THE PROPOSED SUPERVISOR(S)
Supervisor 1Name:(Title / First Name / Surname) Department/Division: Telephone (work): Mobile: Email:
Supervisor 2Name:(Title / First Name / Surname) Department/Division: Telephone (work): Mobile: Email:
6. PROPOSED COMMENCEMENT DATE
7. DEPARTMENT LETTER OF SUPPORT
A letter from the Head of the Department, supporting the application, and confirming that the Department can provide appropriate facilities and supervision for the proposed research, should the application be successful – to be included as an attachment to the application.Letter Attached: YES NO
8. REFEREE REPORTSThe applicant must request a written report from two (2) referees. This report should be from someone other than the PICU Unit Head or PICU Nursing Unit Head. The report should include the referees’ name, address, and contact details and outline the applicant’s abilities and personal suitability to undertake the proposed research project.
Reports may be forwarded by the closing date: Hard copy to: The Matthew Scriver PICU Nurses’ Scholarship, C/- Research Secretariat, Level 2, Samuel Way Building, Women’s and Children’s Health Network, 72 King William Road, NORTH ADELAIDE SA 5006 or via email to [email protected]
REPORTS ATTACHED: YES / NO
REFEREE AName:(Title / First Name / Surname)
Postal/Delivery Address: (include: Floor / Level / Building)
Department /Division:
Telephone (work): Mobile: Email:
REFEREE BName:(Title / First Name / Surname)
Postal/Delivery Address: (include: Floor / Level / Building)
Department /Division:
Telephone (work): Mobile: Email:
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9. ETHICAL/SAFETY CLEARANCES This section MUST be completed as you will require research ethics and governance before you can commence your project. To verify what clearances are required refer to:http://www.wch.sa.gov.au/research/committees/index.html . Please note: The Chief Investigator must provide notification of ethics and governance approval to the Research
Secretariat before the project can commence. Approval for your project will not been granted until written confirmation is received from the relevant ethics/safety
committee and/or Research Governance Officer.
Approval required Approval attached Approval number(s)Human Research Ethics Yes No Ethics:
Governance: Is the title of you proposed project the same as the approve ethicsYes No
Yes
No If NO approval, has application been submitted: Yes No If NO, when will you submit: / /
If you have indicated above that ethics approval is not required, please provide justification below that your study does not involve any patients, patients’ families, patient tissue (including stored tissue), patient information and staff. It is recommended you discuss your project with the Chair of the WCHN Human Research Ethics Committee to clarify this matter and provide written confirmation from the Chair.
10. BUDGETDetail how the money ($3,000) will be spent and state any costs which will and/or may be met from other sources e.g. Departmental support etc.
11. OTHER INFORMATIONThe applicant should provide any other information which may help in the assessment of the application.
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12. CERTIFICATIONAll applications are to be signed, dated and endorsed, as outlined below, by the Applicant, Department Head, Divisional Director and Executive Director.
APPLICANTSignature: ________________________ Date: _____________
Endorsement of Application
DEPARTMENT HEADAcknowledging consent and support for the application and budget provision during the Scholarship
Name: _______________________________________________
Signature: ________________________ Date: _____________
DIVISIONAL DIRECTORName: _______________________________________________
Signature: ________________________ Date: _____________
EXECUTIVE DIRECTORName: _______________________________________________
Signature: ________________________ Date: _____________
13. SUBMITTING APPLICATIONThe applicant is required to submit:
a) An electronic copy of the application to be sent via email to: [email protected] in a Word document format, signatures NOT required on the electronic copy. Also attach any additional supporting documentation (ie CV, relevant supporting letters etc).
b) The original signed (hard copy) of the application form, with all relevant attachments (CV, Supporting letter and referees letter).
NB: The application form must be typed and not hand written and addressed to:
The Matthew Scriver PICU Nurses’ ScholarshipResearch Grants Officer, Research SecretariatLevel 2, Samuel Way Building,Women’s and Children’s Health Network72 King William RoadNORTH ADELAIDE SA 5006
Applications must be submitted by: 4.00pm Monday, 30 October 2017
NB: Late and/or unsigned applications WILL NOT be accepted.
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