Academic Fellowship Application Form

Section A – Applicant Details

Name*

Title First name Surname

Is your proposed primary academic supervisor a member of the SSA?*

Why are you applying to the SSA specifically for this funding?*

Give details of any previous SSA funding you have received, including the specific scheme and dates:*

Scheme	Date (month/year)

Applicant Career

Post held:*

Organisation:*

Department:*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Telephone & extension:*

Mobile*

Email*

Correspondence email address (if different from above):

Correspondence address (if different from above):

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of commencement:*

Professional Qualifications*

Qualification	Subject	Class	Awarding Body	Date (Month/Year)

Prizes, awards and other academic distinctions*

Prize	Awarding Body	Date (Month/Year)

Employment History*

Job title	Organisation	Start date (month/year)	End date (month/year)

Research Experience

(i) Please describe your previous research experience. Describe research methods used and any resulting publications. Give dates and describe your role in the research:*

(ii) Please select one area of your research work to date, and describe the contribution that it has made to the addictions field. Explain your own personal contribution to this area of research (150-300 words):*

Other Academic Experience

Please describe other academic experience such as teaching, mentoring, supervisory roles held, or similar:*

Section B - Proposed Body of Research

Content

Please upload your description of the proposed body of research studies, include details of research hypotheses, methods, anticipated outputs, and intended interaction with or influence upon the addictions policy or practice communities.

This document should be at least 1000 words, and not more than 2000 words (references can either be included or can be attached separately as an appendix [i.e. outside the word count]).

Please start with a short lay summary of the proposed area of work and its importance and relevance to the work of the Society (100-200 words), followed by a description of the proposed body of research, using a structure of your choice but including:

statement of testable hypotheses (or equivalent);
description of the structure or design of the planned specific investigations;
identification of planned research methods and instruments;
your plan for data analyses (including clarification of your current level of competence with the proposed analytical methods, and how you intend to address any deficit);
your expectations about scientific yield, and
your intended methods of dissemination and influence from your work.

Section C – Proposed Fellowship Employment and Career Development

When do you propose to start the fellowship? (month/year):*

Expected duration (maximum 3 years, or pro-rata if part-time, up to a maximum of 5 years):*

Are you seeking fellowship support on a full-time or part-time basis?*

Full-time
Part-time

If part-time, indicate percentage basis:

Do you have other employment or training (e.g. as a clinician, teacher) which you expect will continue during the course of your research and therefore may be relevant to any funding you may receive?*

Yes
No

If YES, please give full details:

At what grade would you (if award granted) be employed? Give full salary costs (with detailed breakdown):*

List any increments you expect or are likely to receive, during the course of the proposed fellowship:*

Please describe your long-term career development aspirations:*

Describe and justify the costs requested, including salary and all other costs:*

Section D – Academic Host Organisation

Institution:*

Department:*

Primary academic supervisor (title, first name and surname):*

Title First name Surname

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Email*

Previous success of academic supervisor and the host institution*

(i) Please describe the standing of the proposed academic supervisor. This should include a statement of the supervisor’s track record in supporting research development in the addictions field, as well as a summary of their own academic standing and research output.We will seek confirmation of these details directly from your supervisor, and will assume your consent to do this, unless you inform us otherwise:

*

(ii) Please describe the reasons for selecting this particular academic host institution and the relevance it will have, and the benefits it will bring to your proposed research study:

Confidential letter of support from primary academic supervisor

We will write to your primary academic supervisor, named above, to confirm the information you have provided in section D. If appropriate supporting information is not received within fourteen days of our letter, your application will be rejected.

Section E - Referees

Referees*

Please provide the names and contact details (including email addresses) of two referees who will be able to comment on your suitability for an SSA academic fellowship. This would ordinarily include your current senior supervisor (or equivalent).

Name	Position	Address	Email

After online submission, please forward a hard copy of your application to this address:

SSA Executive Office, Temple Chambers, Russell Street, Keighley, BD21 2JP