J M O'Hara Research Fund Grant Application Form 2024
The pdf below has application information only. It shows the details that are required to complete the online application form only. This online application form should be used for grant applications. There is a Save whilst in progress option. It is recommended all information is collated prior to commencing the form. Maximum wordcount is applied for each of the questions as indicated.
Project Title
Contact Information
Lead Applicant
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Postal Code
Prefix (e.g. Dr, Prof etc.)
Phone Number
Please enter a valid mobile phone number.
E-Mail Address
example@example.com
Employment Title
Place of Employment
Place of Employment Address
Street Address
Street Address Line 2
City
State
Postal code
Year first registered as a pharmacist
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Research Team
Please complete for all other members of the research team
Researcher 2
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
Researcher 3
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
Researcher 4
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
Researcher 5
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
Researcher 6
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
Researcher 7
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
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Grant Request
Amount of Grant Requested (ex GST)
In-kind Costs
Total Project Budget
Do you have other funding for this research?
Yes
No
If yes please disclose source
Amount of other funding
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Project Information
Background
Provide a description of the background information and literature review (with references) that has led to the proposed research.
0/750
Aim
Indicate the aim(s) of the research and/or the research questions
0/250
Significance
Describe how the outcome(s) from the proposed research will benefit the profession of Pharmacy and/or the health and wellbeing of Western Australians.
0/250
Research Plan
Provide a description of how and where the proposed research will be undertaken.
0/1000
Outcome
Describe the potential outcomes of the research
0/250
Translation and Sustainability
Describe how the results of the research may be implemented or translated in order to impact or influence policy and/or pharmacy practice. Comment also on the likelihood of further development or funding to encourage a practice change approach in addressing persistent social, economic and behavioural issues affecting health outcomes.
0/250
Describe the role of the applicant and each researcher
0/250
Timeline
Provide a timeline for project activities including the proposed commencement and completion dates, and date for provision of a final report to PSWA.
0/250
Budget and Justification
List all sources of funds already available for this project, and other pending applications for funding of the same research. List the budget items and amounts, providing a brief justification for them.
0/250
Budget input option
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Consumer Involvement
Describe how consumers have been involved in the design and development of the research andhow hte views of consumers, the community and/or other end users have informed the proposed research.
0/250
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Risk Management
Where do you consider there are risks in the feasibility of this project, and how will you mitigate this? Consider information, people and delivery risks.
0/250
Risk Management input option
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Communication of Results
Describe the team’s plans for communication of results through future forums, conference presentations, publications, government reports etc. and how these may benefit the JMOHRF and PSWA.
0/250
Summary
Provide a 200-word summary outlining in layman’s terms the background, aims and potential benefitsof the project
0/250
Research References
0/500
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Referees
Provide the full names and contact details of two (2) professional referees for the principal investigator who may be contacted by the JMOHRF AC.
Referee 1
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
Referee 2
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid mobile phone number.
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Curriculum Vitae
Attach a brief CV (max two pages using same format) of the applicant and all researchers listed above. Please list only publications from the last five years, highlighting up to five that are considered the researchers most significant publications.
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Signature - I undertake to abide by the conditions described in the attached J M O’Hara Research Fund Grant Information 2023 and any other conditions placed on the grant by the Pharmaceutical Society of Western Australia Inc.
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
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