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Research Action Awards application form

1. Applicant detailsTitle: First Name: Surname:

Organisation: Position:

Mobile: Level of experience:

Year your PhD was conferred:

If you are more than 15 years post doctorate, please provide a justification for why your application should be considered. If you do not hold a PhD, please provide justification to demonstrate equivalent level of experience.

(2000 characters maximum)

2. Details of your research and its impact on policy, programs or service delivery

Note: The research must have had an impact on policy, programs or service delivery in the past five years.

Describe your research project or program of research. Include brief comments on purpose, background, aims, method, findings and implications.

(3000 characters maximum)

List up to three of the most significant publications that have emerged from this research and attach a copy of each publication as part of your pdf formatted application. Please tick the box once you have attached them: ☐

Please describe the impact on policy, programs or service delivery from your research.

(3000 characters maximum)

Please describe the contribution of yourresearch on policy, programs or service delivery (i.e. Would it have happened without your research? Did it make a

(3000 characters maximum)

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major or minor contribution to the overall impact?).

Please describe the significance of the impact of policy, programs or service delivery on health or health services (e.g. wellbeing, quality of life, mortality, cost efficiencies of service provision, number of people affected).

(3000 characters maximum)

3. Verification

Please provide verification of the impact of your research on policy, programs or service delivery. Please ensure at least one (preferably both) form of verification is included in the application: Select the verifications you are providing:

If you are not able to provide both forms of verification, please provide a justification:

(2000 characters maximum)

Complete this section for verification by research user: (Ensure you have asked for permission before including the person’s personal information.) Person who has agreed to verify your research and its impact on policy, programs or service delivery:

Title: First Name: Surname:

Position: Organisation:

Telephone: Email:

Submission of Verification Form: The nominated research user must submit a separate Verification Form DIRECTLY to the Sax Institute in confidence. Please tick the box once you have arranged for the Verification Form to be submitted. Note that the Sax Institute will not follow up with the research user and you must make sure that it is submitted by 5pm, 22 September 2017. ☐

Please complete this section for verification by documentary evidence:

List reports/policy documents (e.g. key reports, discussion papers, publications or articles, presentations, and/or policy documents) that you are citing as evidence for the impact of your research. Please indicate page numbers or other to aid in location of the relevant text. Attach copies of all listed documentary evidence at the end of application form as part of your pdf formatted application. Please tick the box once you have attached the evidence: ☐

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Privacy statement Your personal information is being collected by the Sax Institute in order to assess your application for this Award. If you are not successful in your application, we will retain your application on file indefinitely. We will handle your information in accordance with the Privacy Act 1988 (Cth) and our Privacy Policy and are committed to respecting and protecting your privacy. If you have received communication from us and you no longer wish to receive those sorts of communications, please email communications@saxinstitute.org.au or call (02) 9188 9500. If you have a query on how your personal information is collected or used or wish to update your details, contact us by email, phone or write to: The Privacy Officer, Sax Institute PO Box K617 Haymarket NSW 1240.

4. Signature of applicant

Name of the applicant:

Signature: / /2017