HRB Host Institution Application Form PLEASE NOTE: The review

HRB Host Institution Application Form
PLEASE NOTE: The review process following receipt of the application may take between six to eight
weeks.
Please refer to Section 8 for a copy of the HRB’s Host Institution Policy
Name of Applicant
Organisation:
Address:
SECTION 1 – LEGAL STRUCTURE
1.1
What is the legal status of the applicant organisation (tick appropriate box)?
Company limited by guarantee
Voluntary Hospital
Partnership
Charity
Higher Education Institution
Other (provide details)
Trust
Limited Company
Sole trader
State Agency
Government Department
Companies Registration
Office No. (if applicable)
Charity
Registration
Number(if applicable)
Revenue Commissioner
CHY No. (if applicable)
Evidence of registration with Charities Regulatory Authority. Please include a print out of the charities register
page covering the applicant organisation from https://www.charitiesregulatoryauthority.ie/
1.2
Set out the aims and objectives of the applicant organisation (refer to Memorandum and articles of
incorporation, corporate strategy etc.)
1.3
Complete the following table in respect of;
 Subscribers of a Company Limited by Guarantee
 Shareholders of a Company Limited by Shares
 Beneficial Owners of the assets/liabilities of the applicant organisation e.g. Department Minister
Name
Address
Occupation
% ownership/
shareholding
1
2
3
4
5
6
7
8
(insert more lines if required)
1.4
Have the assets of the applicant organisation been provided as security for any loan or other benefit?
Yes
No
If the answer to question 1.4 is ‘yes’ then please complete Section 1.5 below.
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1.5
Complete the table below providing full details on; (a) the loan or other benefit secured, (b) whether
the applicant or another person/legal entity is the beneficiary of the loan or other benefit, (c) the
security holder(s).
The Applicant Organisation must provide written confirmation from each of the security holder(s) that the Grant
Monies will never be called upon to satisfy any loan payments or repayment of other benefits of the Applicant
Organisation. (Confirmation should be submitted on the headed note paper of the Security Holder, addressed to
the Health Research Board and submitted together with this application)
Details of loan or other
benefit secured*
Name of beneficiary of the
loan or other benefit
Name of Security
holder(s) on loan or
other benefit
Date of letter from
security holder to HRB
*(including original value and value on the date of signing this Host Institution application form)
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SECTION 2 – FINANCIAL INFORMATION ON APPLICANT ORGANISATION
2.1
Attach a copy of the most recent set of financial statements of the applicant organisation.
2.1(a) Where the financial statements are audited please include the audit opinion.
2.1(b) Where the financial statements are not audited due to exemption please include a certificate from the
accountant of the entity confirming there have been no amendments to the accounts and attesting to
the accuracy of the financial statements.
2.1(c) Please provide a copy of the current tax clearance certificate of the entity or if a charity the revenue
letter confirming tax exemption status.
2.2
Please complete the table below to show the organisation’s total income from research during the past
five financial years as per the financial statements of the organisation.
Year-end date
1
Total Research Income
from Irish Government
sources (Exchequer/Public
funding)
2
Total Research Income
from Charitable Sources
3
Total Other Research
Income
dd mm yyyy
€
dd mm yyyy
€
dd mm yyyy
€
dd mm yyyy
€
dd mm yyyy
€
Total Research Income
2.3
Taking each of the categories above 1 – 3, please outline the sources of research funding received within
the last five years in the following format;
Category Title of award
2.4
Funding
Body
Duration of
award
Amount funded €
Please complete the table below to show the organisation’s total expenditure on research during the
past five financial years as per the financial statements of the organisation.
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Year-end date
dd mm yyyy
€
dd mm yyyy
€
dd mm yyyy
€
dd mm yyyy
€
dd mm yyyy
€
Health Related
Research
Expenditure
Other Research
Expenditure
Total Research
Expenditure
Surplus/
(Deficit)
2.5
Please describe in detail the system(s) and processes in place in the applicant organisation to ensure
effective financial management of research awards (please refer to the organisations’ Standard
Operating Procedures where applicable) in line with the HRB general terms and conditions.
Please include details such as
 Internal financial controls at grant set up, budget management (including proposed budget changes) and
close out,
 financial record keeping processes,
 processes and controls to ensure that the Principal Investigator and the Research Team comply in full
with the HRB’s General Terms and Conditions for Research Awards and any special conditions of a
grant.
SECTION 3 – Research Administration, Support & Governance
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3.1
Please outline the research vision, mission and objectives of the applicant organisation. Provide a
copy of the most recent Research Strategy (or equivalent), if available.
3.2
Please describe the resources, supports, infrastructure and systems in place in the applicant
organisation to ensure compliance with the HRB General Terms and Conditions. At a minimum, you
should include in your description the following:
i.
Support and advice for preparation, sign-off and submission of research grant
applications;
ii.
Award contract negotiation and acceptance (including subcontracts);
iii.
Reporting, certification, monitoring and close-out of awards (including systems in place
for engaging with Principal Investigators to ensure compliance with all obligations of the
award);
iv.
Ensuring compliance with all relevant statutory and regulatory requirements e.g. data
protection, ethics approval;
v.
Effective procurement practices and asset management/maintenance;
vi.
Procedures for managing Intellectual Property for publically funded research (with
reference to the national protocol entitled “Inspiring Partnership- the national IP
Protocol 2016: Policies and resources to help industry make good use of public research
in Ireland”);
vii.
Appropriate research governance practices, policies and systems;
viii.
Supporting effective dissemination and communication from research awards
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3.3
Can the applicant organisation provide evidence for compliance with section nine “Liability, Indemnity
and Insurance” of the HRB general terms and conditions?
Yes
No
If yes, briefly describe below;
3.4
Provide details for each member of core staff that is engaged in research administration, support &
governance, in the following format (excluding staff already listed in question 2.3):
Examples may include; Personnel involved in approving grant submissions, Contracts, Technology
Transfer, Technology platforms, Communications, Ethics etc.
Name
Qualifications Role
within Full Time or
organisation
Part Time
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Date
of Date
appointment ends
contract
Page 7
SECTION 4 – Research Capacity
As an indicator of the level of activity as a research performing organisation;
4.1
Please provide details for each category of research staff actively involved in conducting health research
in the applicant organisation within the last 5 years in the following format:
Type of
Researcher
Number per
Year
(insert year)
Number per
Year
(insert year)
Number per
Year
(insert year)
Number per
Year
(insert year)
Number per
Year
(insert year)
MSc Student
PhD Student
Technician
Research Assistant
Post doctoral
scientist
Principal
Investigator
Project Manager
Research Nurse
Study
Co-ordinator
Statistician
Other
(insert more lines if required)
4.2
Outputs and Outcomes from research funding within the last five years:
Year
(insert year)
Year
(insert year)
Year
(insert year)
Year
(insert year)
Year
(insert year)
Number of higher
degrees supported
*Number of
Publications
Other…..
(insert more lines if required)
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* Please provide full details of all publications noted above as an appendix to this application
4.3
Please describe the resources, supports, infrastructure and systems in place in the applicant
organisation to ensure compliance with the HRB General Terms and Conditions in relation to
recruitment, training and development (including mentoring and supervision) of research personnel
across all career stages and in all relevant aspects of health-related research
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SECTION 5 – HRB GENERAL TERMS AND CONDITIONS DECLARATION
Declaration
I have read and understand the above requirements and declare that the information provided is true and
accurate.
I have read, understand and agree with the HRB General Terms and Conditions
Signature: ______________________
Authorised Signatory of the Applicant Organisation
Date:_______________________
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SECTION 6 – ORGANISATION CONTACTS & SIGNATORIES
6.1 Person responsible for authorising the submission of research grant applications (GEMS Pre Award
Contact)
Name
Job title
E-mail address
Telephone number
6.2 Person responsible for co-ordinating the administration* of successful awards (GEMS Post Award Contact)
* The GEMS Post-award contact will be the HRB contact point for all communication to and from the Host
Institution in relation to the following activities:
- contracts
- payment notifications
- progress reports (annual, end-of-grant etc)
- variations (requests for change to the grant contract)
- ad hoc notifications regarding active grants
It is anticipated that the nominated contact in the Applicant Organisation will be responsible for triaging such
communications/queries, liaising with the appropriate person(s) within their organisation and coordinating
responses.
Name
Job title
E-mail address
Telephone number
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6.3 Person responsible for signing award contracts on behalf of the Applicant Organisation**
Name
Job title
E-mail address
Telephone number
Sample signature
6.4 Person responsible for signing off on award financial reports on behalf of the Applicant Organisation**
Name
Job title
E-mail address
Telephone number
Sample signature
** The HRB would expect the applicant organisation to demonstrate a segregation of duties between the
contract signee and the financial report signee.
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6.5 Please provide the bank account details of the nominated account of the Applicant Organisation for
receipt of funding from the HRB.
Account Name
Bank Name
Bank Address
BIC
IBAN
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SECTION 7: CHECKLIST OF ACCOMPANYING DOCUMENTS
No
1.
2.
Description of Document Required
Evidence of the legal status
e.g. Certificate of Incorporation, copy of memorandum and
articles of association, or legislation establishing the institution
Section of
application form
referring to
document
Tick if
included in
application
Section 1.1
Letter from security holder if applicable
Section 1.5
4.
5.
6.
Audit opinion or Accountant Certification
Section 2.1
Tax Clearance Cert or Revenue Commissioner Letter
Section 2.1
Research Strategy
Section 3.1
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SECTION 8: HRB Host Institution Policy
HRB Host Institution Policy
Effective from 01 July 2015
The policy of the Health Research Board is that an approved Host Institution for the purpose of administering
HRB research awards must be a legal entity which fulfils the responsibilities of “Host Institution” as set out in the
HRB General Terms and Conditions for research awards.
The current list of research performing organisations that are HRB Host Institutions is located on our website at
the link below;
http://www.hrb.ie/research-strategy-funding/policies-guidelines-and-grant-conditions/policies-and-positionstatements/approval-of-host-institutions/
Research performing organisations seeking HRB Host Institution Status must satisfy all of the following
conditions:
1. The organisation must be a legal entity
2. The organisation must demonstrate financial soundness
3. The organisation must warrant that it can comply in full with the HRB General Terms and Conditions
4. The organisation must be able to demonstrate a capability to manage heath related research awards
and possess an existing in-house capacity to carry out research that materially extends and enhances the
Irish research base.
5. The organisation must be based in the Republic of Ireland (funding outside of Ireland may be allowable
where there is no established research capacity in Ireland (e.g. for the case of rare diseases).
All organisations wishing to apply should complete the “HRB Host Institution Application Form” as set out below
and return the completed form to [email protected]
Following submission of the HRB Host Institution Application Form, staff at the HRB will assess if the
organisation meets the criteria set out in the Policy. Please note this process may take between six to eight
weeks.
Once HRB Host Institution status has been granted, it will last for a period of 5 years. The approval status of Host
Institutions may be the subject of periodic review. If the status of a Host Institution changes during this period
the Host Institutions eligibility to apply to our schemes will require re-consideration.
If an application is unsuccessful, HRB will provide feedback and an opportunity to re-apply will be available.
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