Ian Scott Scholarship Application

SCHOLARSHIP APPLICANT
Applicant Name:*

First NameLast Name
Proposed commencement of PhD:*
(month/year)
Proposed Department and Institute:*
Academic Qualifications: *
Year of Birth*
Postal Address*

Street Address

Street Address Line 2

CityState

Postcode
Applicant Email*
example@example.com
Phone Number:

Area CodePhone Number
Mobile Number:*

Area CodeMobile
Australian Citizen:*

YesNo
Permanent Resident of Australia:*

YesNo
I am an International student applying for the Australian Rotary Health/ The Hancock Family PhD Scholarship*

YESNO

Previous Research Experience of Scholarship Applicant*
Please provide details of any relevant research experience e.g. research electives, full/part time research employment or any additional qualifications.
Summary of Project*
In plain english/lay language
Research Project Plan, Aims, Potential Significance & Backround - File Upload*

List the specific aims of the project. If hypotheses are to be tested, they should be clearly stated. Provide a description of how you selected the project and how the results from your study will help to improve the health of Australians. (Maximum 2 Pages).
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References*
List all references identified in this application
Publications of Scholarship Supervisor #1 or Leading Supervisor during the last 2 years*
Please list only published papers and papers accepted for publication in refereed journals from the past two years here.
Funding received for other projects by the scholarship Supervisor #1 or Leading Supervisor in the last 2 years*

CERTIFICATION OF HEAD OF DEPARTMENT AND INSTITUTION
This form will be sent digitally to all three supervisors and Head of Department and Institution.

Please nominate the Head of Department and Institution below
Department Head Name*

First NameLast Name
Department Head Email*
example@example.com
Head of Institution*

First NameLast Name
Head of Institution Email*
example@example.com

ETHICS APPROVAL
Approval by an Institutional Ethics Committee is required for any research on human subjects. Please note that “research” in this context includes any trial experiment, clinical or community-based intervention, collection of blood samples or other biological materials, questionnaire or survey, review of case notes or access to medical records. If the agency or institution which will be responsible for administeringthe grant does not itself have an Ethics Committee set up accordingto NHMRC guidelines, it should arrange for research proposals to be reviewed by a local institution which does have such a committee.
The Report from the Institution’s Ethics Committee is ...*

Included with this applicationWill be forwarded to the Research Officer at Australian Rotary Health
Institution’s Ethics Committee Report - File Upload

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Does this project involve the in vitro production of recombinant DNA molecules?*

YesNo

CONTACT DETAILS OF REFEREES FOR SCHOLARSHIP APPLICANT

Please provide below the contact details of THREE referees. A proforma is attached to send to the referees. Instructions will direct the referees to send the reports directly to Australian Rotary Health. Please note it is the scholarship applicant’s responsibility to ensure that referee reports are received by Australian by the closing date.
Referee 1 - Honours Supervisor or Postgraduate Co-ordinator
Referee #1 Name*

First NameLast Name
Employing Department and Institution:*
Referee #1 Email*
example@example.com
Phone Number*

Area CodePhone Number
Referee 2 - PhD Supervisor
Referee #2 Name*

First NameLast Name
Employing Department and Institution:*
Referee #2 Email*
example@example.com
Phone Number*

Area CodePhone Number
Referee 3 - Non-Academic referee
Referee #3 Name*

First NameLast Name
Employing Department and Institution:*
Referee #3 Email*
example@example.com
Phone Number*

Area CodePhone Number

Final tasks
The contents of your submission will now be sent to the respective Supervisors, Department and Institution Head for final sign off approvals. You will be alerted when the document has moved through the authorisation process.
Should be Empty:

Ian Scott Scholarship