Health Care and Promotion Scheme Application Form

Ref. No.
(for official use)
Health and Medical Research Fund
HEALTH CARE AND PROMOTION

SCHEME APPLICATION FORM
The personal data provided in the application form will be used by the Research Council, the Health Care and
Promotion Committee, the Promotion Sub-Committee (PSC), and the Research Fund Secretariat for the
purpose of assessing applications to the Health Care and Promotion Scheme (HCPS) under the Health and
Medical Research Fund (HMRF). For successful applications, such data will also be used for project
monitoring, research and statistical analysis, promotion, publicity and dissemination purposes as appropriate.
Contents of the submitted application set out in Sections 1 to 9 with the status of project will be made available
for public access once funding approval is offered.
ATTENTION:
A. Before completing this form, please read carefully the Guidance Notes - Grant Application for
Health Care and Promotion Scheme and Explanatory Notes - Grant Application for Health Care and
Promotion Scheme (Application materials can be downloaded from the website at
https://rfs.fhb.gov.hk). Applications will not be considered if the information supplied by the
applicants is incomplete or inaccurate. The Government reserves the right to request additional
documents and information when processing the applications.
B. This form should be typed in Arial of 11 point or above. Application can be submitted in English
with or without Chinese version. If both English and Chinese versions are submitted, applicants
must indicate the prevailing version to be referred to, in case there is inconsistency or ambiguity
between the two.
C. Application for funding recurrent costs of the same health promotion project is not acceptable.
D. Principal Applicant(PA) should check the box below before completing the application form -
☐ I have read and understood the Guidance Notes - Grant Application for Health Care and
Promotion Scheme and Explanatory Notes - Grant Application for Health Care and Promotion
Scheme
☐ I understand that application which is incomplete, inconsistent with the submission requirements,
or insufficiently detailed to be processed by the Research fund Secretariat may result in
administrative withdrawal.
E. PA should check the box below to indicate the version to be submitted before completing the
application form and the prevailing version if both English and Chinese versions are submitted -
☐ I will submit English version only.
☐ I will submit both English and Chinese version, and the prevailing version is English in case there
is inconsistency or ambiguity between the two.
☐ I will submit both English and Chinese version, and the prevailing version is Chinese in case
there is inconsistency or ambiguity between the two.
HMRF (Health Care and Promotion Scheme: Application Form Version: 2.0)
Updated: May 2018 1
1. SUBMISSION
☐ New Project ☐ Re-Submission (Please complete Section 2 below)
2. RE-SUBMISSION
(applicable only for application with rating “Re-submission” or “2” in the Promotion
Sub- Committee (PSC) Assessment Report)
Previous Ref. No.:

Rating of previous submission:
Please attach structured response to PSC Assessment Report as Appendix

The structured response can be completed in English or Chinese. If it is completed in Chinese, the
PA has to provide an English version.
3. PROJECT TITLE (Word limit: 25 words)
4. EXECUTIVE SUMMARY (Limited to one A4 page and 400 words)
 Aim and Objectives

 Target Group and Size
 Deliverables
 Key Milestones
 Total Financial Support Requested
HMRF (Health Care and Promotion Scheme: Application Form Version 2.0)
Updated: May 2018 2
4a. PROPOSED PROJECT THEMATIC PRIORITY (please select one thematic priority only)
☐ Tobacco control
☐ Lifestyle, nutrition and physical activity
☐ Mental well-being
☐ Injury prevention
☐ Reducing alcohol-related problems
☐ Promoting family doctor model of care
☐ Empowering patients and the community in the management of chronic diseases and
strengthening preventive care in children and older adults
☐ Cancer prevention
☐ Breastfeeding
☐ Healthy use of internet and electronic screen products
☐ Organ donation
☐ Others (Please specify:______________________________________)
4b. KEYWORDS
5. POTENTIAL BENEFITS
Please explain the likely benefit to the health needs of the target community in Hong Kong this
application will address, in quantifiable terms if possible. (Word limit: 100 words)
Updated: May 2018 3
6. PROPOSED START AND END DATES (dd/mm/yyyy)
6a. Start Date: 6b. End Date: 6c. Grant Period: months
7. SUMMARY OF FINANCIAL SUPPORT REQUESTED
(dd/mm/yy) 01/04/ - 31/03/ 01/04/ - 31/03/ 01/04/ - 31/03/ Total (HK$)
Staff
Other Expenses
Equipment
Sub-Total
Grand Total
8. ETHICS APPROVAL/CONSENT FOR ACCESSING THIRD-PARTY DATA (IF APPLICABLE):
Please complete this section if ethical approval from an institutional review board and/or consent for
accessing third-party data have been received. Otherwise, state the current progress in Section 13(j).
Date Received Reference No.

(dd/mm/yyyy)
1
2
3
(Note: Please add additional row(s) in above table as appropriate)
9. APPLICANTS (PROJECT TEAM)
PA
Title (Prof/Dr/Mr/Mrs/Ms)
Last name
First name
Current post(s)
Department
No. of hrs/week on project
Full address Department
Institution
Room/Floor
Building
Street
Area/City
Country
Tel (direct/secretary)
Fax
E-mail
Updated: May 2018 4
Applicant 2
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Applicant 3
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Applicant 4
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Updated: May 2018 5
Applicant 5
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Applicant 6
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Applicant 7
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Updated: May 2018 6
Applicant 8
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Applicant 9
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Applicant 10
Last name
First name
Current post(s)
Department
Institution
Room/Floor
Building
Street
Area/City
Country
Fax
E-mail
Updated: May 2018 7
10. DETAILS OF FINANCIAL SUPPORT REQUESTED
10a. STAFF DETAILS

(Salary increase should not be included.)
Details of Posts Salary/ Efforts on No. of Staff Costs for

Month Project # Months Entire Project
Types of Staff Pay
(A) (B) (C) Required AxBxCxD
Rank Scale HK$ % (D) HK$
No.
& Point
# % of effort = Actual monthly working hours x 100%

Total monthly working hours of a full time staff
10b. STAFF COSTS (To the Nearest HK$)
Financial Year HK$

(dd/mm/yy) 01/04/ - 31/03/ 01/04/ - 31/03/ 01/04/ - 31/03/ Total
Total Costs
Updated: May 2018 8
10c. OTHER EXPENSES (To the Nearest HK$)
(Including equipment costs less than $10,000/unit)
Please specify (itemise in details, i.e. item, number required, cost per unit, etc.)
HK$
Financial Year
(dd/mm/yy) 01/04/ - 01/04/ - 01/04/ -
Total
31/03/ 31/03/ 31/03/
Audit Fee
(Up to $5,000 if
requesting at or below
$1,000,000 or $10,000
if requesting over
$1,000,000)
Incentives for
participants (if any)
Volunteers’ subsidies
(Up to $70 per day per
volunteer)
Conference (i.e. Travel

and subsistence) (Up
to $10,000)
Publication costs
(For disseminating
results in journals) (Up
to $20,000)
Reference materials
(e.g. downloads of
scholarly articles) (Up
to $5,000)
Total Costs
Updated: May 2018 9
10d. EQUIPMENT (To the Nearest HK$)
(Complete this section only if equipment costs $10,000/unit or above. If equipment costs less than
$10,000/unit, itemise under “Other Expenses”.) The lowest tender/quotation should be accepted.
Please specify (itemise in details, i.e. item, specification, model number, number required, cost
per unit, etc.)
Financial Year HK$

(dd/mm/yy) 01/04/ -31/03/ 01/04/ -31/03/ 01/04/ -31/03/ Unit Price Total
Total Costs
Updated: May 2018 10
11. HMRF, OTHER SUPPORT, SIMILAR OR RELATED PROPOSALS AND TRACK RECORD
THIS APPLICATION
11a. (i) Have any of the applicants listed in Section 9 submitted this or a similar ☐ Yes ☐ No
proposal to the HMRF (including Investigator-initiated research
projects, Health Care and Promotion Scheme, Research Fellowship
Scheme) or any of its preceding funding schemes, or other funding
agencies (local or overseas) in the past three years?
Attention: In this section include all previously submitted similar proposals in the
past 3 years, i.e. proposals rejected or not supported by HMRF or other funding
agencies. For each of the above similar proposal(s), please provide the following
(as attachments) -
a copy of the previous application, the reviewers’ comments (if any), a point-by-
point response to the reviewers’ comments, and/or a description of the differences
or changes made between the previous and the current proposal.
Failure to provide sufficiently detailed information may adversely affect the
assessment of your proposal.
If yes, please provide the following details:-
For proposal(s) pending a funding decision, please complete Section 11a. (ii) below.
No. Project Title Name of Project Funding Funding

Applicant(s) Ref. No. Agency Decision
/Rating
1
Please give a brief response to the points mentioned in the attached review panel’s feedback
(if any), highlight the major changes that have been incorporated in this application.
Applications declined for any reason by HMRF or other funding organisations will be accepted
only if the reasons for the rejection have been described in details and a point-by-point
response is provided describing how these issues have been addressed.
11a. (ii) Do any of the applicants listed in Section 9 intend to submit this or a ☐ Yes ☐ No
similar proposal to the HMRF (including Investigator-initiated research
projects, Health Care and Promotion Scheme, Research Fellowship
Scheme) or any of its preceding funding schemes, or other funding
agencies (local or overseas) in the next six months?
Attention: At any time before the announcement of the funding decision of this
application, applicants are required to notify the Research Fund Secretariat
immediately about -
(a) any other similar or related application submitted to other funding agencies in
addition to those listed below; and
(b) the funding decision once available.
If yes, please provide the following details -
No. Project Title Name of Project Funding Expected Date

Applicant(s) Ref. No. Agency of Decision
(dd/mm/yyyy)
1
Please give a summary of the similarities and differences between this application and the
proposal to be submitted (400 words max).
OTHER APPLICATIONS AND TRACK RECORD
11b. (i) Has the PA listed in Section 9 been awarded grant(s) from the HMRF ☐ Yes ☐ No
(including Investigator-initiated research projects, Health Care and
Promotion Scheme, Research Fellowship Scheme) or any of its
preceding funding schemes, or other funding agencies (local or
overseas) in the past three years?
If yes, please provide the details of grant(s) funded or undertaken by PA (in a PA/
Co-Applicant (Co-A) capacity)
No. Project PA/ Project Funding Funding Start Date Completion Time
Title Co-A Ref. No. Agency Amount (dd/mm/yyyy) Date Spent
($) (dd/mm/yyyy) by PA
on the
Project
(hrs/%)
1
awarded project (400 words max).
11b. (ii) Have any of the Co-Applicants (Co-As) listed in Section 9 been ☐ Yes ☐ No
awarded grant(s) from the HMRF (including Investigator-initiated
research projects, Health Care and Promotion Scheme, Research
Fellowship Scheme) or any of its preceding funding schemes, or other
funding agencies (local or overseas) in the past three years?
If yes, please provide the details of grant(s) funded or undertaken by Co-A (in a PA capacity)
No. Project Name of Project Funding Funding Start Date Completion

Title Applicants(s) Ref. No. Agency Amount (dd/mm/yyyy) Date
($) (dd/mm/yyyy)
1
2
3
awarded project (400 words max).
12. DECLARATION AND AUTHORISATION
Do the Administering Institution or any of the applicants listed in Section 9, or

any of the proposed personnel and sub-contractors/agencies to be engaged in
☐ Yes ☐ No
the project, have any actual or perceived conflict of interest, such as receiving
any funding or assistance directly or indirectly from industries (including but not
limited to tobacco related businesses, infant formula companies, or
organisations funded by such businesses)?
If yes, please provide -

a. The nature of relationship; and
b. Duration of the relationship.
Applicants
I certify that the statements herein are true, and accurate to the best of my knowledge. I am aware
that any false, fictitious, under declaration, fraudulent statements or claims may subject me to criminal,
civil, or administrative penalties. I agree to accept responsibility for the conduct of the project, to abide
by the Conditions for Use of the HCPS and to provide the required interim, final and dissemination
reports if a grant is awarded as a result of this application.
I authorise the Research Fund Secretariat to handle the personal data/information provided in this
application in accordance with Section 3.5 of the Guidance Notes.
Signature of Applicant(s) Name (Capitals) Date
1.
(PA)
2.
3.
4.
5.
6.
7.
8.
9.
10.
Administering Institution
This application should be endorsed and submitted by/through (i) the Head of Agency (in non-
governmental organisation (NGO)) or Head of Department (in tertiary institution), (ii) the officer who
will be responsible for administering any grant that may be awarded and (iii) the finance officer who
will be responsible for overseeing/administering the related finance matters. Each party should be
asked to complete the following declaration.
I certify that the statements herein are true, complete and accurate to the best of my knowledge, and
accept the obligation to comply with the Conditions for Use of the HCPS if a grant is awarded as a
result of this application.
(i) Signature of HEAD of AGENCY (in NGO)/

HEAD of DEPARTMENT (in tertiary institution)
NAME (BLOCK): DATE:
DEPARTMENT:
EMAIL ADDRESS:
(ii) Authorised Signature on behalf of ADMINISTERING

INSTITUTION:
POSITION HELD:
NAME (BLOCK): DATE:
ADMINISTERING
INSTITUTION:
(iii) Signature on behalf of FINANCE OFFICER/TREASURER:
NAME (BLOCK) DATE:
Address of FINANCE
OFFICER/TREASURER:
TEL: FAX:
13. PROPOSED PROJECT
(a) Title:
(b) Justification for conducting the project:

(i) Health needs of the local community (supported by published data or relevant
experiences)
(ii) Literature review on others’ strategies to address these needs
(iii) Scientific evidence supporting the strategies to address these needs proposed in this
project
(c) Aim and Objectives:
(d) Project Plan:

(i) Target group
(ii) Implementation plan
(iii) Contingency/alternative plan if any problem encountered during implementation
(iv) Cross-sector collaboration
(v) Indicators and targets
(vi) Evaluation plan
(vii) Results analysis
[Word Count: ]
(e) Existing Facilities:
(f) Justification of Resource Requirements:

(i) Details
(ii) Estimated revenue or recurrent income (if any) to offset the expenditure of the project
(iii) Supplementary sponsorship (monetary or non-monetary) (if any) to cover any expenditure
or resource requirement of the project
(g) Purpose and Potential:

(i) How will this project enhance your community’s capacity to promote health in the long run
(ii) How the project can be sustained after the funding period
(h) Key References:
(i) Timetable of work
Time Key Milestones Deliverables

(months after project
commencement)
Example:
6 months Completion of participant recruitment List of enrolled participants
(j) Ethics approval/consent for accessing third-party data (if applicable)

Note: The primary responsibility for seeking the relevant approval rests with the Principal
Applicant.
Please check the appropriate boxes to confirm if approval for the respective ethics and/or consent
for accessing third-party data is required and has been obtained or is being sought.
For details regarding Independent Ethics Committee/Institutional Review Board, please refer to
Section 3 of this document published by the International Council for Harmonisation available
from the following link -
http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6/E6_R2__St
ep_4_2016_1109.pdf
Copies of written documentation of approval and/or consent issued by proper authorities, or of

application for approval and/or consent, should be submitted in good time and preferably with the
application.
Ethics/consent for accessing third-party data Approval/ Approval/ Approval/

consent not consent being consent
required sought obtained
Approval from an institutional review board
(i) Human research ethics ☐ ☐ ☐

(ii) Survey research ethics ☐ ☐ ☐
Any other approval
(e.g. consent for accessing third-party data) ☐ ☐ ☐
Please specify:
14. REPORT ON PREVIOUS GRANTS FROM THE HMRF (INCLUDING INVESTIGATOR INITIATED
RESEARCH PROJECTS, THE HEALTH CARE AND PROMOTION SCHEME, RESEARCH
FELLOWSHIP SCHEME), OR ANY OF ITS PRECEDING FUNDING SCHEMES.
For each of the above grants which you or any of your Co-Applicants have held as PA, including projects
currently underway and completed projects in the last three years, please give the information requested
below. If more than one award, please copy a blank form for completion and insert behind this table.
Project Reference No.:
Project Title:
Started on: (dd/mm/yyyy) Completed/To Complete on: Final Report Submitted on:
(dd/mm/yyyy) (dd/mm/yyyy)
PA:
Current perception of significance:
Publications/Scientific papers directly resulting from this grant:
Reasons for delay in the submission of interim, final and/or dissemination reports, if applicable:
15. CURRICULUM VITAE (CV) AND ROLES & RESPONSIBILITIES OF ALL APPLICANTS
Limit to one page for each CV, starting with PA. Do not attach your own CV or use template other
than this form.
PA
*Title: Prof/Dr/Mr/Mrs/Ms Last name: First name:
Education/Training:
Position and Honours (in reverse chronological order with dates):
Experience on the same and related subject of the Proposed Project/Recent Relevant Publications:
Role and Responsibility on the Proposed Project:
* Please delete where inappropriate.
Applicant
*Title: Prof/Dr/Mr/Mrs/Ms Last name: First name:
Education/Training:
Position and Honours (in reverse chronological order with dates):
Experience on the same and related subject of the Proposed Project/Recent Relevant Publications:
Role and Responsibility on the Proposed Project:
* Please delete where inappropriate.

Note: Please copy the table as appropriate.

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Ref. No.

(for official use)

Health and Medical Research Fund

HEALTH CARE AND PROMOTION

☐ I will submit English version only.

☐ New Project ☐ Re-Submission (Please complete Section 2 below)

Previous Ref. No.:

Please attach structured response to PSC Assessment Report as Appendix

3. PROJECT TITLE (Word limit: 25 words)

4. EXECUTIVE SUMMARY (Limited to one A4 page and 400 words)

 Aim and Objectives

☐ Lifestyle, nutrition and physical activity

☐ Reducing alcohol-related problems

☐ Promoting family doctor model of care

☐ Healthy use of internet and electronic screen products

☐ Others (Please specify:______________________________________)

7. SUMMARY OF FINANCIAL SUPPORT REQUESTED

(dd/mm/yy) 01/04/ - 31/03/ 01/04/ - 31/03/ 01/04/ - 31/03/ Total (HK$)

8. ETHICS APPROVAL/CONSENT FOR ACCESSING THIRD-PARTY DATA (IF APPLICABLE):

Date Received Reference No.

9. APPLICANTS (PROJECT TEAM)

10a. STAFF DETAILS

Details of Posts Salary/ Efforts on No. of Staff Costs for

# % of effort = Actual monthly working hours x 100%

10b. STAFF COSTS (To the Nearest HK$)

Financial Year HK$

Conference (i.e. Travel

Financial Year HK$

If yes, please provide the following details:-

No. Project Title Name of Project Funding Funding

If yes, please provide the following details -

No. Project Title Name of Project Funding Expected Date

No. Project Name of Project Funding Funding Start Date Completion

Do the Administering Institution or any of the applicants listed in Section 9, or

If yes, please provide -

Signature of Applicant(s) Name (Capitals) Date

(i) Signature of HEAD of AGENCY (in NGO)/

NAME (BLOCK): DATE:

(ii) Authorised Signature on behalf of ADMINISTERING

NAME (BLOCK): DATE:

(iii) Signature on behalf of FINANCE OFFICER/TREASURER:

NAME (BLOCK) DATE:

(b) Justification for conducting the project:

(ii) Literature review on others’ strategies to address these needs

(c) Aim and Objectives:

(d) Project Plan:

(ii) Implementation plan

(iii) Contingency/alternative plan if any problem encountered during implementation

(iv) Cross-sector collaboration

(v) Indicators and targets

(vi) Evaluation plan

(vii) Results analysis

(e) Existing Facilities:

(f) Justification of Resource Requirements:

(g) Purpose and Potential:

(i) Timetable of work

Time Key Milestones Deliverables

(j) Ethics approval/consent for accessing third-party data (if applicable)

Copies of written documentation of approval and/or consent issued by proper authorities, or of

Ethics/consent for accessing third-party data Approval/ Approval/ Approval/

(i) Human research ethics ☐ ☐ ☐

Project Reference No.:

Current perception of significance: