ELIGIBILITY FORM CHECKLIST
This form will be used in conjunction with the application to determine the applicant’s eligibility for specific scholarships and fellowships and will assist RACS in the allocation of awards.
If you satisfy the eligibility conditions outlined in the statement please TICK the “Are you Eligible” column if you wish
to apply for this award. Please sign this page.
Award
Conditions Statement
Conditions Statement
Are you eligible
Eligible?
Conditions Statement
John Mitchell Crouch
Fellowship Are you a RACS Fellow? Did you obtain your FRACS and/or comparable
overseas qualification within the past 15 years (2005 or later)?
Are you making a significant contribution to the advancement of surgery or to fundamental scientific research?
Are you working actively in the field?
Will you use this Fellowship to assist in the continuation of this work?
If successful, do you intend to attend the Convocation ceremony at the RACS Annual Scientific Congress (ASC) in the year of the Fellowship for a formal presentation, where you must be prepared to make a 20-25 minute oral presentation on your research work including the contribution arising from the award? Are you a resident of Australia or New Zealand? Note that this award is not available to FRACS applicants.
I confirm that I have read the Important General Conditions and meet the eligibility requirements as
stated on this form.
Signed ________________________________________ Date ________________________
SECTION A – Applicant’s Details
Surname/Family nameGiven Names Title Gender Full Postal address (including
State and Postcode
Is this a work or home address? Home Telephone Business Telephone Mobile Number Email ORCID Number
Do you currently hold a FRACS? YES NO APPLIED
Please note this award is not available to FRACS applicants What year did you gain your Fellowship? YEAR:
What is your specialty?
Do you have restrictions placed on you or your practice by a regulatory authority or hospital? YES NO If yes, please provide details:
Are any aspects of you or your practice under review? YES NO If yes, please provide details:
SECTION B – Qualifications
1 Do you have post graduatequalifications? YES NO
2 If YES to 1, please list your university qualifications and post graduate degrees, including the following information:
SECTION C – Employment details
3 Please complete the following details relating to your present employment: Employer/Source of
Funding: Tenure:
(If untenured please give date of termination of current post)
Grade/Status
4 Please list your five PREVIOUS post-graduate appointments in date order, starting from your most recent.
5 Please briefly detail below any noteworthy academic achievements in your career to date
6
List what you consider to be your five most important publications. Please state impact
factors and range for your specialty.
1.
2.
3.
4.
5.
7
Please provide a list of up to five of the most important national or international lectures you havebeen invited to deliver.
1.
3.
4.
SECTION D – Project details
8 Please provide a brief statement about your current research work and your future plans, including a detailed proposal on how you will use the funds from the Fellowship if you are successful.
9
Does the project
involve experiments
on human or animal
subjects?
HUMAN
ANIMAL
N/A
10
If yes to either of the
above, has the
relevant ethics
Committee of the
Institution concerned
approved that the
project conforms to
the general
principles set out in
the NHMRC…
“Statement on
Human
Experimentation”
“Australian Code of
Practice for the Care
and Use of Animals
for Scientific
Purposes”
Not Yet
Not Yet
Documentary
evidence required
11
In your research, do you plan to identify and
compare statistically significant differences
in sex/gender study participants (human or
animal)?
YES
NO
12
If so, please briefly explain how
13
If not, please briefly explain why not
If your research relates to a sex/gender specific topic, please note this
SECTION F – Signature
I certify that the information supplied in this application is true and correct. I understand that the Royal Australasian College of Surgeons may wish to verify this information with an institution or individual. I consent to such inquiries being undertaken as part of the RACS Scholarships and Fellowships selection process. I have read the application conditions for the relevant Fellowship and agree to abide by them.
Signature: ___________________________________________________ (e-signature required)
Date:
