IN CONFIDENCE OFFICE USE ONLY

AUSTRALIAN WOMEN & CHILDREN’S RESEARCH FOUNDATION

(OZWAC)

APPLICATION FOR MEDICAL RESEARCH PROJECT GRANT SUPPORT

1 CHIEF INVESTIGATORS: Chief Investigator A will be considered the contact point for the project grant

and will be understood to be acting for and in concurrence with all chief investigators.

	SURNAME	TITLE	INTITIALS
A
B

2 CURRENT WORK CONTACT DETAILS: Postal/Email Address,

Telephone/Fax Nos.

3 (a) SCIENTIFIC PROJECT TITLE: State scientific title of project, be concise but informative.

DO NOT exceed 75 characters including spaces.

(b) LAY PROJECT TITLE: Provide a simple lay title for the project for use in future media releases if

required. DO NOT exceed 75 characters. Complete in full – DO NOT INDICATE “AS ABOVE”.

4 OTHER FUNDING AGENCIES: Complete below if seeking support from this project from any other

funding agency. eg. PHRDC, RADGAC, AKF, ARG, CARG etc.

Name and address of Agency:

5 CLEARANCE REQUIREMENTS: (It is essential that parts (a) – (c) are answered)

(a)	Research involving humans – Mark Y/N	Y/N
(i)	Does this project include research involving humans. (This includes the administration, to humans, of drugs, chemical agents or vaccines)?
(ii)	If YES to the above, is the completed FINAL clearance form attached?
(b)	Experiments on animals – Mark Y/N
(i)	Does this project involve experimentation on animals?
(ii)	If YES, is the completed FINAL clearance form attached? Provisional clearances will not be accepted.
(c)	Other clearances – Mark Y/N
(i)	Does this project involve organisms being genetically manipulated such as that it falls under current Genetic Manipulation Advisory Committee guidelines?
(ii)	If YES, is the completed FINAL clearance form attached? Provisional clearances will not be accepted.
(iii)	Does this project involve the use of carcinogenic or highly toxic chemicals?
(iv)	If YES, is a signed statement indicating an awareness of the “Guidelines for Laboratory Personnel Working with Carcinogenic or Highly Toxic Chemicals” and the completed FINAL Biosafety clearance form attached? Provisional clearances will not be accepted.

Section (e) and (f) must be completed when either human or animal experimentation is involved in a project. A brief statement of the ethical issues which arise from such experimentation, and an explanation of how these issues will be addressed, must be given.

It is not sufficient to note that “the Australian Code of Practice for the Care and Use of Animals for Scientific Purposes/NHMRC Statement on Human Experimentation will be observed”.

CLEARANCE REQUIREMENTS…..Continued

(e) Ethical Implications of the Project Experiments on Humans

A signed completed Ethics Committee approval should be submitted with this application, or a statement made that the project has been submitted to the committee for approval.

(f) Ethical Implications on the Project Experiments on Animals

A signed completed Ethics Committee approval should be submitted with this application, or a statement made that the project has been submitted to the committee for approval.

6 BUDGET ITEMS:

DETAILED BUDGET FOR FIRST YEAR OF PROJECT	AMOUNT REQUESTED
ITEMS	$

Amount Requested

1st year

$

2nd year

$

3rd year

$

Justification of the budget

7 SALARY REQUESTED FOR ANY NAMED CHIEF INVESTIGATOR:

Where salary support for any of the above named investigators is sought within the budget of this application, please complete below

(a) Chief Investigator A, B, C or D		Current Appointment
Current Salary	$	Source of Salary
Salary Level Sought	$	Designation
(b) Chief Investigator A, B, C or D		Current Appointment
Current Salary	$	Source of Salary