All studies that are supported through this workshop must adhere to our terms of support which are available here. Concept Development Workshop Application Form Name* First Last Institution/OrganisationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* MobileWhat stage is this concept at? (Select one)*0 - (I dreamt of this last night)12345 - (I'm ready to apply for funding)Project Title Background and rationaleAim ObjectivesPopulation and settingInterventionsStudy designStudy design diagramAttach any relevant study design diagrams, if appropriate. Max. file size: 24 MB.Outcomes and measuresPatient Reported OutcomesIs your project likely to contain any Patient Reported Outcomes (PRO) or PRO measures? (Select Yes or No)YesNoInvestigatorsPlease include any (potential) or confirmed investigators or working group members. List potential members in brackets. Statistical ConsiderationsFeasibilityHas this concept had any consumer input up to now? (Select Yes or No)YesNoIf yes, please describe.Consumer SummaryPlease provide a lay summary of your concept including why the research is being proposed, the impact to research community and the benefit to the community.Are there any specific questions you would to ask consumers?Below are some possible questions. Check all that apply. Would the burden on the patient in this intervention be acceptable? Do they have any concerns about the intervention design? Could the intervention be changed to reduce the burden on participants? Does this study address a question they feel is important for cancer patients? Are there any ways they feel consumers could be further engaged in the project? Are the outcomes in this project important from a consumer perspective? If you were approached to participate in this study, would you? Why/why not? From a consumer perspective, what is the greatest strength of this study? From a consumer perspective, does this study have any weaknesses? Other Please list any other consumer questions belowPlease list any other consumer questions belowMoving forward, would you be interested in any of the following additional support for this project from PC4? Consumer AI for a grant application A consumer for the project Steering Committee Input from our GP circle (a community of GPs and practice nurses that provide input on study design and feasibility) Grant application review Design of trial recruitment materials Assistance with trial protocol development In the next 12 months do you intend to apply for funding for this concept? (Select Yes or No)YesNoIf YES, Which of the following funding schemes do you intend to apply to (select all that apply) MRFF NHMRC Which NHMRC Grant Scheme/s? NHMRC Project grant NHMRC Investigator grant NHMRC CRE/program grant NHMRC Synergy NHMRC Clinical trials and cohorts grant NHMRC Ideas grant Cancer Australia PdCCRS State/Terriority/Goverment (e.g. CNISW, VCA) Cancer Councils/Foundations Other Please list other grant scheme below CAPTCHA
