Early Career Researcher Expression of Interest FormPurpose The Early Career Researcher Network (ECRN) is a platform governed by the PC4 Scientific Committee to assist and help new researchers in their career growth. ECRN members will engage with senior researchers and other ECRN members to develop their own research portfolio. Commitment ECRN members are required to develop at least one PC4 supported project or collaborate with a PC4 initiated project. It is expected that members will attend the ECRN workshop. Membership is for three years with the possibility of extension. Eligibility Only PC4 members are eligible for nomination for the ECRN. Membership is free, so please sign up here. Process Members are invited to nominate themselves using this Expression of Interest form. Nominations will be submitted to the PC4 Office for review. Applicants will be notified of the outcome via email. Personal DetailsName* Mr.Mrs.MissMs.Dr.Prof.A/ProfMx Prefix First Last Email* Enter Email Confirm Email Street Address City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary work location* Postcode State Phone*Please give a brief overview of you professional and research experienceCurrent role* Higher Degree By Research (HDR) - see 1.1 and 1.3 Post-doctoral Research – see 1.2 Clinician (exclusively) - see 1.3 Research Officer/Assistant – see 1.3 Other – specify, see 1.3 1.1 Please provide more information regarding your HDR experienceHDR Title(e.g. PhD in Medicine)Date of confirmation/date conferredThesis titleDiscipline/UniversityPrimary SupervisorAdditional Supervisors1.2 Please provide more information regarding your postdoctoral experience. (List most recent if multiple post doctorates)Check here if you have multiple post-doctorates Yes Research TopicDate started Research Summary(100 words)Discipline/InstitutionCheif Investigators1.3 Please provide a summary of your clinical and/or research experience 1.3 Please provide a summary of your clinical and/or research experience1.4 Does your research and/or clinical experience involve these demographic groups? (tick all that apply)1.4 Does your research and/or clinical experience involve these demographic groups? Indigenous Australians Torres Strait Islanders NESB/CALD SEIFA 2.1 Please tell us how the ECRN and PC4 may help you in your career development and interests2.1 Please tell us how the ECRN and PC4 may help you in your career development and interests*2.2 Please tell us how your skills and experience will contribute to PC42.2 Please tell us how your skills and experience will contribute to PC4*3. What type of activities/topics would you like the ECRN to cover? (Please tick all that apply)3. What type of activities/topics would you like the ECRN to cover? (Please tick all that apply)* Career development Concept development workshops Peer review workshops Statistics Quality of life measurements Mentorship program Ethics Presentations Journal article preparation Systematic reviews Grant submissions Networking events Trial/data management OtherMembershipsMemberships AGITG ASSG ALLG ANZBCTG ANZCHOG ANZGOG ANZMTG ANZUP CNSA COSA COGNO PoCoG TROG OtherHow did you hear about PC4?*PC4 websitePC4 EmailTwitterColleagueInternet searchConferenceOther** If Other, please specify.Please add any additional comments regarding your application here:Please add any additional comments regarding your application here:Please upload your CV*
