Form A - for health promotion project Web view(Word limit: 25 words) ... E-mail ... Hospital Authority

Health and Medical Research Fund

HEALTH CARE AND PROMOTION SCHEME APPLICATION FORM

The personal data provided in the application form will be used by the Research Council, the Health Care and Promotion Committee, the Promotion Sub-committee (PSC), and the Research Fund Secretariat for the purpose of assessing applications to the Health Care and Promotion Scheme (HCPS) under the Health and Medical Research Fund (HMRF). For successful applications, such data will also be used for project monitoring, research and statistical analysis, promotion, publicity and dissemination purposes as appropriate. Contents of the submitted application set out in Sections 1 to 9 with the status of project will be made available for public access once funding approval is offered.

ATTENTION:

A. Before completing this form, please read carefully the Guidance Notes - Grant Application for Health Care and Promotion Scheme and Explanatory Notes - Grant Application for Health Care and Promotion Scheme (Application materials can be downloaded from the website at http://rfs.fhb.gov.hk). Applications will not be considered if the information supplied by the applicants is incomplete or inaccurate. The Government reserves the right to request additional documents and information when processing the applications.

B. This form should be typed in Arial of 11 point or above. Application can be submitted in English with or without Chinese version. If both English and Chinese versions are submitted, applicants must indicate the prevailing version to be referred to, in case there is inconsistency or ambiguity between the two.

C. Application for funding recurrent costs of the same health promotion project is not acceptable.

D. Principal Applicant should check the box below before completing the application form:

☐ I have read and understood the Explanatory Notes and Guidance Notes - Grant Application

for Health Care and Promotion Scheme.

☐ I understand that application which is incomplete, inconsistent with the submission

requirements, or insufficiently detailed to be processed by the Research fund Secretariat may

result in administrative withdrawal.

E. Principal Applicant should check the box below to indicate the version to be submitted before completing the application form and the prevailing version if both English and Chinese versions are submitted:

☐ I will submit English version only.

☐ I will submit both English and Chinese version, and the prevailing version is English in case

there is inconsistency or ambiguity between the two.

☐ I will submit both English and Chinese version, and the prevailing version is Chinese in case

there is inconsistency or ambiguity between the two.

HMRF (Health Care and Promotion Scheme: Application Form Version: 1.0)Updated: April 2017 1

Ref. No. (for official use)

http://rfs.fhb.gov.hk/

1. SUBMISSION

☐ New Project ☐ Re-Submission (Please complete Section 2 below)

2. RE-SUBMISSION (applicable only for application with rating “Re-submission” in the PSC Assessment Report)

Previous Ref. No.:

Rating of previous submission:

Please attach structured response to PSC Assessment Report as AppendixThe structured response can be completed in English or Chinese. If it is completed in Chinese, the Principal Applicant has to provide an English version.

3. PROJECT TITLE (Word limit: 25 words)

4. EXECUTIVE SUMMARY (Limited to one A4 page and 400 words)

Aim and Objectives Target Group and Size Deliverables Key Milestones Total Financial Support Requested

HMRF (Health Care and Promotion Scheme: Application Form Version 1.0) Updated: April 2017 2

4a. PROPOSED PROJECT THEMATIC PRIORITY (please select one thematic priority only)

☐ Tobacco control

☐ Lifestyle, nutrition and physical activity

☐ Mental well-being

☐ Injury prevention

☐ Reducing alcohol-related problems

☐ Promoting family doctor model of care

☐ Empowering patients and the community in the management of chronic diseases and strengthening preventive care in children and older adults

☐ Cancer prevention

☐ Breastfeeding

☐ Healthy use of internet and electronic screen products

☐ Organ donation

☐ Others (Please specify:______________________________________)

4b. KEYWORDS

5. POTENTIAL BENEFITS:

Please explain the likely benefit to the health needs of the target community in Hong Kong this application will address, in quantifiable terms if possible. (Word limit: 100 words)


6. PROPOSED START AND END DATES (dd/mm/yyyy)

6a. Start Date: 6b. End Date: 6c. Grant Period: months

7. SUMMARY OF FINANCIAL SUPPORT REQUESTED

(dd/mm/yy) 01/04/ - 31/03/ 01/04/ - 31/03/ 01/04/ - 31/03/ Total (HK$)

Staff

Other Expenses

Equipment

Sub-total

Grand Total

8. ETHICS APPROVAL / CONSENT FOR ACCESSING THIRD-PARTY DATA (IF APPLICABLE):

Please complete this section if ethical approval from an institutional review board and / or consent for accessing third-party data have been received. Otherwise, state the current progress in Section 13(j).

Date Received(dd/mm/yyyy)

Reference No.

1

2

3

(Note: Please add additional row(s) in above table as appropriate)

9. APPLICANTS (PROJECT TEAM)

Principal ApplicantTitle (Prof/Dr/Mr/Mrs/Ms) Last name First name

Current post(s)

Department

No. of hrs/weeks on project Full address Department

Institution Rm/Floor Building Street Area / City Country

Tel (direct/secretary) Fax E-mail


Applicant 2Title (Prof/Dr/Mr/Mrs/Ms) Last name First name

Current post(s)

Department





Current post(s)

Department





Current post(s)

Department






Current post(s)

Department





Current post(s)

Department





Current post(s)

Department






Current post(s)

Department





Current post(s)

Department





Current post(s)

Department





10. DETAILS OF FINANCIAL SUPPORT REQUESTED

10a. STAFF DETAILS(Salary increase should not be included.)

Types of StaffDetails of Posts Salary/

MonthEfforts on Project #

No. of Months

RequiredStaff Costs for Entire Project

RankPay

Scale & Point

(A)No.

(B)HK$

(C)%

(D) A x B x C x DHK$

# % of effort = Actual monthly working hours x 100%Total monthly working hours of a full time staff

10b. STAFF COSTS (To the Nearest HK$)

Financial Year (dd/mm/yy)

HK$01/04/ - 31/03/ 01/04/ - 31/03/ 01/04/ - 31/03/ Total

Sub-Total

Total Costs


10c. OTHER EXPENSES (To the Nearest HK$) (Including equipment and capital expenditure cost less than $10,000/unit)

Please specify (itemise in details, i.e. item, number required, cost per unit, etc.)Financial Year (dd/mm/yy)

HK$01/04/ -31/03/ 01/04/ -31/03/ 01/04/ -31/03/ Total

Audit Fee (Up to $5,000 if requesting at or below $1,000,000 or $10,000 if requesting over $1,000,000)

Incentives for participants

Volunteers’ Subsidies (Up to $70 per day per volunteer)

Conference (i.e. Travel and subsistence) (Up to $10,000)

Publication costs(For disseminating results in journals) (Up to $20,000)

Reference materials(e.g. downloads of scholarly articles) (Up to $5,000)

Total Costs


10d. EQUIPMENT (To the Nearest HK$) (Complete this section only if equipment and capital expenditure cost $10,000/unit or more. If equipment and capital expenditure costs less than $10,000/unit, itemise under “Other Expenses”.) The lowest tender/quotation should be accepted.

Please specify (itemise in details, i.e. item, specification, model number, number required, cost per unit, etc.)Financial Year (dd/mm/yy)

HK$01/04/ -31/03/ 01/04/ -31/03/ 01/04/ -31/03/ Unit Price Total

Total Costs


11. HMRF, OTHER SUPPORT, SIMILAR OR RELATED PROPOSALS AND TRACK RECORD

THIS APPLICATION

11a. (i) Have any of the applicants listed in Section 9 submitted this or a similar proposal to the Health and Medical Research Fund (including Investigator-initiated research projects, Health Care and Promotion Fund/ Scheme, Research Fellowship Scheme) or any of its preceding funding schemes, or other funding agencies (local or overseas) in the past 3 years?

☐ Yes ☐ No

If yes, please provide the following details:-

For proposal(s) pending a funding decision, please complete Section 11a. (ii) below.

No. Project Title Name of Applicant(s)

Project Ref No.

Funding Agency

Funding Decision / Rating

1 2

3 4

5 6

For each of the above similar proposal(s), please provide the following (as attachments): -A copy of the application; and the review panel’s feedback (if any)

Please give a brief response to the points mentioned in the attached review panel’s feedback (if any), highlight the major changes that have been incorporated in this application. Applications declined for any reason by HMRF or other funding organisations will be accepted only if the reasons for the rejection have been described in details and a point-by-point response is provided describing how these issues have been addressed.


(ii) Do any of the applicants listed in Section 9 intend to submit this or a similar proposal to the Health and Medical Research Fund (including Investigator-initiated research projects, Health Care and Promotion Fund/ Scheme, Research Fellowship Scheme) or any of its preceding funding schemes, or other funding agencies (local or overseas) in the next 6 months?

☐ Yes ☐ No

Attention: At any time before the announcement of the funding decision of this application, applicants are required to notify the Research Fund Secretariat immediately about: (a) any other similar or related application submitted to other funding agencies

in addition to those listed below; and(b) the funding decision once available.

If yes, please provide the following details:-

No. Project Title Name of Applicant(s)

Project Ref No.

Funding Agency

Expected Date of Decision (dd/mm/yyyy)

1

2

3

Please give a summary of the similarities and differences between this application and the proposal to be submitted (400 words max).


OTHER APPLICATIONS AND TRACK RECORD

11b. (i) Has the Principal Applicant listed in Section 9 been awarded grant(s) from the Health and Medical Research Fund (including Investigator-initiated research projects, Health Care and Promotion Fund/ Scheme, Research Fellowship Scheme) or any of its preceding funding schemes, or other funding agencies (local or overseas) in the past 3 years?

☐ Yes ☐ No

If yes, please provide the details of grant(s) funded or undertaken by PA (in a PA/ Co-A capacity)

No. Project Title PA/Co-A

Project Ref No.

Funding Agency

Funding Amount ($)

Start Date(dd/mm/yyyy)

Completion Date(dd/mm/yyyy)

Time Spent by PA on the Project (hrs/ %)

1

2

3

Please give a summary of the similarities and differences between this application and the awarded project (400 words max).



11b. (ii) Have any of the applicants listed in Section 9 been awarded grant(s) from the Health and Medical Research Fund (including Investigator-initiated research projects, Health Care and Promotion Fund/ Scheme, Research Fellowship Scheme) or any of its preceding funding schemes, or other funding agencies (local or overseas) in the past 3 years?

☐ Yes ☐ No

If yes, please provide the details of grant(s) funded or undertaken by Co-A

No. Project Title Name of Investigator(s)

Project Ref No.

Funding Agency

Funding Amount ($)

Start Date(dd/mm/yyyy)

Completion Date(dd/mm/yyyy)

1

2

3

Please give a summary of the similarities and differences between this application and the awarded project (400 words max).


12. DECLARATION AND AUTHORISATION

Do the Administering Institution or any of the applicants listed in Section 9, or any of the proposed personnel and sub-contractors / agencies to be engaged in the project, have any actual or perceived conflict of interest, such as receiving any funding or assistance directly or indirectly from industries (including but not limited to tobacco related businesses, infant formula companies, or organisations funded by such businesses)?

☐ Yes ☐ No

If yes, please provide:a. The nature of relationship; andb. Duration of the relationship

Applicants

I certify that the statements herein are true, and accurate to the best of my knowledge. I am aware that any false, fictitious, under declaration, fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. I agree to accept responsibility for the conduct of the project, to abide by the Conditions for Use of the HCPS and to provide the required progress, final and dissemination reports if a grant is awarded as a result of this application. I have read and understood the Guidance Notes - Grant Application for Health Care and Promotion Scheme.

I authorise the Research Fund Secretariat to handle the personal data / information provided in this application in accordance with section 3.5 of the Guidance Notes.

Signature of Applicant(s) Name (Capitals) Date

1.

2.(Principal Applicant)

3.

4.

5.

6.

7.

8.

9.

10.


Administering Institution

This application should be endorsed and submitted by / through (i) the Head of Agency (in NGO) or Head of Department (in tertiary institution), (ii) the officer who will be responsible for administering any grant that may be awarded and (iii) the finance officer who will be responsible for overseeing / administering the related finance matters. Each party should be asked to complete the following declaration.

I certify that the statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with the Conditions for Use of the HCPS if a grant is awarded as a result of this application.

(i) Signature of HEAD of AGENCY (in NGO) / HEAD of DEPARTMENT (in tertiary institution)

NAME (BLOCK): DATE:

DEPARTMENT:

EMAIL ADDRESS:

(ii) Authorised Signature on behalf of ADMINISTERING INSTITUTION:

POSITION HELD:

NAME (BLOCK): DATE:

ADMINISTERING INSTITUTION:

(iii)Signature on behalf of FINANCE OFFICER/TREASURER:

NAME (BLOCK) DATE:

Address of FINANCE OFFICER/TREASURER:

TEL: FAX:


13. PROPOSED PROJECT

(a) Title:

(b) Justification for conducting the project:

(i) Health needs of the local community (supported by published data or relevant experiences)

(ii) Literature review on others’ strategies to address these needs

(iii) Scientific evidence supporting the strategies to address these needs proposed in this project

(c) Aim and Objectives:

(d) Project Plan:

(i) Target group

(ii) Implementation plan

(iii) Contingency / alternative plan if any problem encountered during implementation

(iv) Cross-sector collaboration

(v) Indicators and targets

(vi) Evaluation plan

(vii) Results analysis

[Word Count: ]

(e) Existing Facilities:

(f) Justification of Resource Requirements:

(i) Details

(ii) Estimated revenue or recurrent income (if any) to offset the expenditure of the project

(iii) Supplementary sponsorship (monetary or non-monetary) (if any) to cover any expenditure or resource requirement of the project


(g) Purpose and Potential:

(i) How will this project enhance your community’s capacity to promote health in the long run

(ii) How the project can be sustained after the funding period

(h) Key References:

(i) Timetable of work

Time(months after project

commencement)

Key Milestones Deliverables

Example:6 months Completion of participant recruitment List of enrolled participants

13(j) Ethics approval / consent for accessing third-party data (if applicable)Note: The primary responsibility for seeking the relevant approval rests with the principal applicant.

Please check the appropriate boxes to confirm if approval for the respective ethics and/or consent for accessing third-party data is required and has been obtained or is being sought.

For details regarding Independent Ethics Committee / Institutional Review Board (IEC / IRB), please refer to Section 3 (pages 9 – 12) of this document published by the International Council for Harmonisation available from the following link: http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6/E6_R1_Guideline.pdf

Copies of written documentation of approval and/or consent issued by proper authorities, or of application for approval and/or consent, should be submitted in good time and preferably with the application.

Ethics/ consent for accessing third-party data Approval / consent not required

Approval / consent being sought

Approval / consent obtained


Approval from an institutional review board

(i) Human research ethics ☐ ☐ ☐(ii) Survey research ethics ☐ ☐ ☐

Any other approval (e.g. consent for accessing third-party data)Please specify:

☐ ☐ ☐


14. REPORT ON PREVIOUS GRANTS FROM THE HEALTH AND MEDICAL RESEARCH FUND (HMRF) (INCL. INVESTIGATOR INITIATED RESEARCH PROJECTS, THE HEALTH CARE AND PROMOTION FUND/SCHEME, RESEARCH FELLOWSHIP SCHEME), OR ANY OF ITS PRECEDING FUNDING SCHEMES.

For each of the above grants which you or any of your co-applicants have held as Principal Applicant, including projects currently underway and completed projects in the last 3 years, please give the information requested below. If more than one award, please copy a blank form for completion and insert behind this table.

Project Reference No.:

Project Title:

Started on: (dd/mm/yyyy) Completed / To Complete on:

(dd/mm/yyyy)

Final Report Submitted on:

(dd/mm/yyyy)

Principal Applicant

Current perception of significance

Publications / Scientific papers directly resulting from this grant:

Reasons for delay in the submission of interim, final and/or dissemination reports, if applicable:


15. CURRICULUM VITAE AND ROLES & RESPONSIBILITIES OF ALL APPLICANTS

Limit to one page for each CV, starting with Principal Applicant. Do not attach your own CV or use template other than this form.

Principal Applicant

*Title: Prof/Dr/Mr/Mrs/Ms Last name: First name:

Education / Training:

Position and Honours (in reverse chronological order with dates):

Experience on the same and related subject of the Proposed Project / Recent Relevant

Publications:

Role and Responsibility on the Proposed Project:

* Please delete where inappropriate.


Applicant

*Title: Prof/Dr/Mr/Mrs/Ms Last name: First name:

Education / Training:

Position and Honours (in reverse chronological order with dates):

Experience on the same and related subject of the Proposed Project / Recent Relevant

Publications:

Role and Responsibility on the Proposed Project:

* Please delete where inappropriate.Note: Please copy the table as appropriate.


Documents

Form A - for health promotion project Web view(Word limit: 25 words) ... E-mail ... Hospital Authority