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AREF Research Development Fellowship 2017: Application Form Version: 04 April 2017

Please read the accompanying Guidance on Completing the Application Form before entering information into this form. This Application Form and the accompanying Guidance (http://www.medicalresearchfoundation.org.uk/aref/2017/04/04/aref-research-development-fellowships-2017/ ) both have five Parts:

A: The Candidate B. The Fellowship Proposal C: Copies of DocumentsD: Other Information E. Signatures F: Checklist (in the Guidance only)Complete this form electronically, using Font Arial 10. Write in the white spaces and not in green or other coloured spaces.You will submit this Form with other documents, which are listed in Section C (and F of the Guidance).

PART A: THE CANDIDATE1. Name of applicant

Given/First name Family/Surname name Title (Dr, Mr, Mrs, Ms)

2. Current contact details Please indicate which address/phone/email you prefer us to use by marking X once in each of the three rows

Home Mark X if preferre

d

Work Mark X if preferre

d

Postal

address

Phone

Email

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http://www.medicalresearchfoundation.org.uk/aref/2017/04/04/aref-research-development-fellowships-2017/

http://www.medicalresearchfoundation.org.uk/aref/2017/04/04/aref-research-development-fellowships-2017/

3. Nationality, Gender, Date of Birth

Nationality (-ies) Gender (Male / Female) Date of birth (dd,mm,yyyy)

4. PhD or equivalent research doctorate

Degree title, e.g. PhD, DPhil, MD

Awarding Institution Registration (Month & Year)(MM/YY)

Completion = Award) (MM/YY)

Title of doctoral Thesis

Summary of doctoral project (Maximum of 120 words)

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5. Other university degrees / diplomas: (Most recent first)

Degree and Class of Degree (indicate Honours Degrees and awards given Distinctions)

Awarding Institution Registration (Year)

Completion = Award) (MM/YY)

6. Academic prizes and distinctions: University level and above

Prize Institution Year (YY)

7. Current employment (or, if not currently employed, your most recent)

Post Institution Date started (and terminated if relevant) (MM/YY)

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Current monthly salary including personal allowances (State currency)

In about 50 words, list and describe your roles in RESEARCH, TEACHING, ADMINSTRATION, MEDICINE or other relevant occupation

Indicate the nature of your employment contract (e.g. unlimited term; fixed-term), and the termination date.

If you are not currently employed, indicate your reason for leaving

8. Preceding employment: (Most recent first)

Position Main duties Institution Start & end dates (MM/YY)

9. For CLINICALLY QUALIFIED applicants only, identify your chosen specialty for higher specialist training; title and dates of specialist training posts held

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10. For ALL applicants, identify any other research-relevant specialist/technical training that you have undertaken, and which you have not identified in the previous sections of the application (e.g. short courses and training attachments)

Course name & date completed

Institution delivering the course / attachment

Training outcome (<12 words per cell)

11. Significant research outputs (research articles: do not include conference presentations)

You should list up to five publications, published or in press (References: List all authors, title of the paper, journal, year of publication, volume and page numbers in that order.

You must attach your best two publications as PDFs, see Part E)

Publication reference Journal Impact Factor

Your contribution or role in the work leading to the publication and in preparing the publication.


PART B: FELLOWSHIP PROPOSALRead the whole of Part B and the accompanying guidance before starting work on it. Word limits for each section have been indicated. The overall word limit is 1500 words, excluding the words of the form itself and your 12 references.You must complete the form in Arial 10 font.

You should use sensible paragraph breaks and simple numbering and bulleting. You can also shorten or lengthen the boxes if they are too big, or small, taking account of the word limit. You may also introduce or amend a page breaks sensibly. Help the reader.Remember to work in Word but submit the document preferably in PDF format after it is signed.

12. Fellowship Title: A simple title that indicates the research challenge that you aim to tackle as a result of this Fellowship. (Maximum 25 words)

13. Research question: Set out a research question that you would like to tackle in the future after and as a result of the Fellowship (Maximum 30 words)


14. Research design: Outline the research design or strategy you would use to address the research question you specified in Section 13 (Maximum of 1000 words text; in addition you may add up to 6 key references).

15. Justification: Why this research question and this design? And why you and your sponsors? (Maximum of 800 words, excluding references).


16. Your researcher development path: (i) Set out your career goal(s) for about 3-5 years from now. (ii) Summarise the steps by which you propose to reach the goal(s). (iii) Describe the specific capabilities you intend to develop during this fellowship. (200 words)

17. Sponsorship, mentoring and collaboration: Identify people who have taken responsibility to help you make your Fellowship successful.

(A) Employing Organisation (EO)


during the Fellowship

Name of EO Institutional Director

Name of your intended EO Academic Sponsor(s)

Email address(es)

How your EO Academic Sponsor(s) will assist you. (Up to 50 words)

(B) Host Organisation (EO) during the Fellowship

Name of HO Institutional Director

Name of your intended HO Academic Sponsor(s)

Email

How your HO Academic Sponsor(s) will assist you. (Up to 50 words)

Name of significant Specialist or Career Mentor(s)

Email(s)

How your Specialist or Career Mentor will assist you. (Up to 50 words)


You are encouraged to ask your Host and Employing sponsors to provide letters of support. (See Guidance)

18. Indicative fellowship plan: Summarize the key stages and activities of your Fellowship Plan in the following three tables (Use Arial 9). Section (18A) covers Preparatory Period at your EO before the placement; (18B) the Placement at the HO; and (18C) the Follow-Up period at your EO after the placement. After Table 18C, you have the option of adding a milestone-based Gannt chart. Milestones must be entered in the Summary Sheet.18A Preparatory period before the placement

Start date of Preparatory period

End date of preparatory period

No. of weeks from start to end

Number of days you plan to spend on preparation during this period

Objectives for the Preparatory Period

1. 2. 3.

Start & end dates of the activity

Activities to prepare for your placement

..to..

..to..

..to..

..to..

Add rows to the tables, if necessary.18B Placement at the Host Organisation



No. of weeks

Objectives for the Placement Period

1. 2. 3. 4. 5.


Activities during the placement


..to..

..to..

..to..

..to..

..to..

..to..

..to..

18C Follow-up period after the placement (12-week maximum)



No. of weeks from start to end

What % (up to 50%) of the Follow-up period will you spend on the following implementation activities?

%

Objectives 1. 2. 3.


Implementation activities related to your future research

..to..

..to..

..to..

Note that you need to complete the Milestones section of the Summary Sheet.19. Plans to transfer knowledge, skills and other benefits to your

Employing Institution


20. Financial request:Summarise here your main categories of costs. You should prepare your Cost & Finance plan using the downloadable Excel template and then transfer the data to this Table.

AREF Cost and Finance Plan: SUMMARY COSTS SHEET

Total cost (GBP) to AREF

Maximum AREF

contribution permitted

(GBP)

Value of contribution of

the HO

20A. Preparatory Period

1 SUBTOTAL (A. Preparatory period)

2 Training preparation

3 Administration e.g. visa

3 Other specified costs

20 B. Placement period

4 SUBTOTAL (B. Placement period)

5 Accommodation, subsistence & settling in

6 Travel to and from Africa & within the host country

7 Contribution to training consumables & publication costs

8 Short courses in advanced methods & researcher-development training

9 International conference(s)


20C. Follow-up period

11 SUBTOTAL (C. Follow-up period)


12 Salary-related costs

13 Research-related costs


GRAND TOTAL 0

21. Justification of resources: Provide a justification for the resources outlined above (up to 700 words)

22. Ethical Considerations: Identify any likely ethical issues that work during your fellowship may give rise to and how they will be managed.


23. Publication references: (A maximum of 3 references specifically related to your proposed Fellowship)

PART C: COPIES OF DOCUMENTSList here the file names of all documents that you are submitting with the application. The file name in the right hand columns in the table below should exactly match the PDF file name.

Application Form, Signatures, Cost & Finance Plan and Summary Sheet

Example for fictitious candidate Dr A B Njogu Example of file name

NjoguAB_Application_AREF2017.PDF andNjoguAB_Cost&Finance_AREF2017.PDF

Your Application Form (Parts A-C)

Your Application Form signatures pages (D)

Your Cost & Finance Plan

Your Summary Sheet

HO and EO Support Letters submitted with the application. Name the institution and provide the filename Example: NjoguAB_EO_Support_Letter.PDF

EO Name and PDF

HO Name & PDF

Degree and other relevant Professional Certificates

Example for fictitious candidate Dr A B Njogu

PhD

Example of file name

NjoguAB_PhD.PDF


Publications You may attach copies of two publications of which you are an author, indicating the reference and PDF file name here

Ref: File name:

Ref: File name:

Other evidence submitted with the application

Name: File name:

PART D: OTHER INFORMATIONMark X in ONE or more boxes to indicate how you heard about this programme or indicate which national newspaper, job vacancy website, research network etc.

MRF website Regional Networks (Which?)

MRC Unit, The Gambia website From a professional colleague

Global Health Network website Other (How?)

PART E: SIGNATURES24. Applicant Signature

PRINT YOUR NAME

YOUR SIGNATURE

JOB TITLE & ORGANISATION

DATE

25. Employing Organisation Authorised Officer

ATTESTATION By signing this application, I approve the costs associated with my organisation as submitted in the application form, and confirm that they are in accordance with the AREF policy on costing.

PRINT YOUR NAME

YOUR SIGNATURE



DATE

26. Host Organisation Academic Sponsor

PRINT YOUR NAME

YOUR SIGNATURE


DATE

27. Host Organisation Authorised Officer

AttestationI approve the costs associated with my organisation as submitted in the application form, and confirm that they are in accordance with the AREF policy on costing.

PRINT YOUR NAME

YOUR SIGNATURE


DATE

SUBMISSION: The application form and accompanying documentation should be submitted as individual files to Mr Lamin Sanneh, AREF Senior Administrative Assistant by email to [email protected] so as to reach AREF by the published deadline of 16.00 hours GMT on 28 June 2017. Applications received after the deadline will not be considered.Your application will be INELIGIBLE if the Form is not completed properly or if the accompanying documents are not complete, or if they are received after the published deadline for receipt of applications. AREF will take sanctions against any applicant who commits a deliberate act of dishonesty in the course of applying for an AREF award. Please read the Guidance that accompanies this form. It gives more information on how to send your documents attached to one or more emails.

END OF AREF APPLICATION FORM
