All applicants should refer to the Request for Proposals document
Health Research Council of New Zealand
Ngā Kanohi Kitea - Application for Development
Grant Form AppDv NKK2012
HRC REF
Section 1A – Summary
Research Title
Named Investigator(s)
Title
First Name
1
2
3
4
(First investigator will be the contact)
Middle Name
Surname
Expand tables as necessary by pressing enter at the end of a row outside of the table
Host Institution
Research Location
Iwi/Hapu/Maori Organisation as Investigator**
** Ensure names of responsible persons are listed in Named Investigator table above
Likely Total Cost of Research:
$
Cost for Development Phase
Funding
$
* the cost of development phase funding must not exceed 5% of the total cost of the
research to a maximum of $10,000
Proposed Term of Research (months)
Contact Details – First Named Investigator will be the Contact Person
Named Investigator 1
Department
Organisation
PO Box/Street number
Suburb
City and Postal Code
Telephone
Fax
Email
Pacific Ethnicity (if relevant)
Iwi & hapu (if relevant)
Named Investigator 2
Organisation
Named Investigator 3
Organisation
AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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All applicants should refer to the Request for Proposals document
Named Investigator 4
Organisation
Copy table and paste if necessary
Nominated independent expert
Full Name
Organisation
PO Box/Street number
Suburb
City and Postal Code
Telephone
Fax
Email
Iwi & hapu (if relevant)
Details of relevant experience – include details of previous research undertaken by
independent expert, experience with proposed methodology etc
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AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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All applicants should refer to the Request for Proposals document
Section 2 – Description of Proposed Research (3 page maximum)
Use may use the following as a guide to structure your description:
 Health or disability issue being addressed in the full study
 Rationale for undertaking this research (i.e. Why is this piece of research important to
the iwi, hapū or community?)
 Proposed methodology/approach to the research
 Potential gains from this research in relation to the health or disability issue
 Involvement of community/partnerships
 Nature of expert advice for development phase (e.g. independent expert, consultation
hui)
 Budget for development grant and brief justification
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AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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All applicants should refer to the Request for Proposals document
Section 3 – Relevance of research to specific population groups
1.
Does your research involve one or more of the HRC's priority population groups?*
Maori (if yes, Q2-7)
Pacific peoples (if yes, Q8-13)
Children and youth (if yes, Q8-13)
Older adults (if yes, Q8-13)
People with disability (if yes, Q8-13)
* You can also complete these sections if your research does not directly involve priority
populations, but you can provide information that would assist the reader to understand
or appreciate the scope of your application.
Section 3A – Questions 2-7
2.
Describe the competency (e.g. cultural, relevant training, networks) of the research
team to undertake the proposed research.
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3.
Identify the Maori groups consulted regarding this application and why and how
they were selected.
Iwi group
Maori health
researchers
Maori health group
Other Maori group
4.
Describe the process used with the above groups in the development of this
application, their recommendations, and if they will have a role in the further
development and/or implementation of this research project, or indicate if not
applicable. (Append any documentation resulting from that consultation).
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5.
If there are Maori participants in the project, how has tikanga been incorporated
into the methodology? For example, what culturally appropriate methods will be
used to recruit, how is data from Maori to be collected, stored and analysed?
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6.
Will this study lead to the development of Maori specific research methods? (If so,
please discuss).
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7.
How, when and to what Maori groups, will the researchers actively disseminate
research results?
AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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All applicants should refer to the Request for Proposals document
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Section 3B – Questions 8-13
Create a subsection within each question for each population group, if relevant to the research
proposal.
8.
How might your research contribute to the health outcomes of the population to be
studied? What is the health significance and context of the research to this
population? (Discuss the incidence or prevalence in this population, or indicate if not
known to be significantly different from the general population.)
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9.
Describe the competency (e.g. cultural, relevant training, networks) of the research
team to undertake the proposed research.
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10.
Identify the stakeholder groups that were consulted regarding this application.
Describe why and how they were selected.
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11.
Describe the process used with the above groups in the development of this
application, their recommendations, and if they will have a role in the further
development and/or implementation of this research project, or indicate if not
applicable. (Append any documentation resulting from that consultation).
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12.
Will the research generate data specific to one or more of these population groups?
If so, please give details below. Describe any methodology of specific relevance to
the study population.
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13.
How, when and to what stakeholder groups, will the researchers disseminate research
results?
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AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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All applicants should refer to the Request for Proposals document
Section 4 – Biographical Sketches
(Must be completed by all Named Investigators)
Full Name
Department
University/Organisation
PO Box/Street number
Suburb
City and Postal Code
Telephone
Email
Pacific Ethnicity (if relevant)1
Iwi & hapu (if relevant)
Gender
If a Named Investigator intends to be absent for a period of longer than one month
during the contract duration, please state the reason:
Period of absence Reason
Degrees/Diplomas
University
Field
Year conferred
Honours, prizes, scholarships, etc
Relevant academic and research experience
Year awarded
From year
To year
Signature
I certify that the information provided is accurate and current.
Sign:
Date:
Name:
1
Pacific Ethnicity - Building the capacity of the Pacific Workforce is an HRC priority; therefore, if relevant
please indicate if the researcher is of Pacific ethnicity.
AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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All applicants should refer to the Request for Proposals document
Number of Publications (exclude abstracts, proceedings or letters published
or presented)
List of Publications from previous five years
- List in reverse date order, starting from current year first,
- AND highlight the ones most relevant to this application, by bolding the Author(s) name
- You may include citations, impact factors, and/or journal rankings
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Other forms of research dissemination (1 page only)
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Other relevant experience (1 page only)
AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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All applicants should refer to the Request for Proposals document
Section 5 – Administrative Agreement (Do not copy. Send with original
proposal only).
All HRC applications must include an undertaking to abide by the following administrative
agreement:
1.
It is understood and agreed that this application and any contract awarded as a
result of this application is subject to the Health Research Council of New Zealand
Rules (“Permissible Use of Research Funding and Operation of Contracts”).
Funds will not be expended for any other purpose than described in this
application.
2.
The host institution agrees and undertakes to bear all risk and claims connected
with any operation covered by this application and to indemnify and hold harmless
the Council against any and all liability suits, actions, demands, costs or fees on
account of death, injuries to persons or property, or any other losses resulting
from or connected with any act or omission performed in the course of the
research.
3.
The host institution agrees and undertakes to support for the duration of any
contract, the work described in this application by making available
accommodation, basic facilities for research and the services necessary for its
fulfilment.
4.
The Head of Department agrees to accept this research within his/her department
if a contract is made, agrees to provide workload relief for research staff working
on this contract (Principles of Full Cost Funding), and is aware that s/he may be
requested by the HRC to provide a confidential assessment of the research during
the term of the contract.
5.
The host institution official designated below agrees to ensure that the research
will have been approved, where necessary, by the appropriate institutional
biosafety committee and/or all other required regulatory agencies before research
is commenced.
6.
The applicant(s) agrees to allow specified personal information to be used for
statutory and publicity purposes.
7.
The host institution has in place policies and processes to ensure that consultation
with Maori has occurred and the application is responsive to the needs and
diversity of Maori.
We the undersigned have read the above administrative agreement and undertake to
abide by the conditions of this agreement in respect of any contract made by the Health
Research Council of New Zealand as a result of this application. We the undersigned
confirm that the information provided in this application is to the best of our knowledge
true, and that all sections are correct at the time of application submission.
NOTE: Only one fully signed copy of this page is required by the Council, this form must be
returned to the Health Research Council of New Zealand with original copy of the contract
application. Applications that do not have a fully completed administrative agreement will not be
processed.
Named Investigator 1
Name:
Signed:
Date:
Authorised official on behalf of host institution
Name:
Signed:
Position:
Host name:
Date:
AppDv NKK 2012 Application form © 2012 Health Research Council of New Zealand. All rights reserved.
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