INTERNAL (UQ RESEARCH & INNOVATION) REVIEW: To initiate UQ R&I internal review, please email this completed and signed Application Certification Form to majorinitiatives@research.uq.edu.au. The UQ R&I internal closing date for applications in Round 2 is 11 September 2023. SUBMISSION OF FINAL APPLICATION: Advice and instructions regarding the final submission of your application to AusIndustry will be forwarded to you and the alternative contact listed below by the UQ R&I reviewing officer. FOR MORE INFORMATION ABOUT THE UQ APPLICATION PROCESS, VISIT THE UQ R&I SCHEME WEBSITE.

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APPLICANT CONTACT INFORMATION
Lead Investigator Name: Including title, e.g. Dr, A/Prof, Prof	Gender:	Select one
Lead Investigator Email:	Phone:
Lead Investigator Level:	Select one
Alternative Contact Name:
Alternative Contact Email:	Phone:

Please note your local Research Management Office will be cc’ed into communications.

SUMMARY APPLICATION INFORMATION
Application Tracking Code:
Application Title:
UQ Admin School/Centre:
UQ Admin Faculty/Institute:
Please advise if your application is receiving (or has received) UQ School/Faculty/Institute internal readership or has been read by a senior colleague.	Yes ☐ No ☐	Please specify: Choose an item.

STATISTICAL INFORMATION
Type of research (must total 100%): Information on the types of research is available from the UQ R&I website. This information is collected for ABS.	Strategic	Experimental	Pure	Applied
%	%	%	%
Fields of Research (FoR) codes (up to 3) FoR codes are available via the UQ R&I website. Please ensure you use 6 digit codes, totalling 100%.	FoR 1	FoR 2	FoR 3
Enter 6-digit FOR	Enter 6-digit FOR	Enter 6-digit FOR
%	%	%
Socio-Economic Objective (SEO) codes (up to 3) SEO codes are available via the UQ R&I website. Please ensure you use 6 digit codes, totalling 100%.	SEO 1	SEO 2	SEO 3
Enter 6-digit SEO	Enter 6-digit SEO	Enter 6-digit SEO
%	%	%

Applicant Checklist – Key action items
All sections of the proposal are complete and valid in the Business Grants Portal.	☐
This Application Certification Form is complete, signed and emailed to UQ R&I to initiate internal review.	☐
All Chief investigators listed in the application are eligible to participate.	☐
All partners have provided Letters of Support for the application.	☐

All certifications must be obtained prior to the submission of the Application to the Medical Research Future Fund (MRFF). The University of Queensland (UQ) will retain this form for its records. Certification may be by handwritten signature on this form, or via e mail provided the e-mail includes the relevant certification statement (below) and the full name, position and contact details of the person certifying. Certifications must be provided by: ● CIA (certifying to a Conflict of Interest statement and the provisions of A) and the head of the UQ host organisational unit (Head of School/Institute/Centre or equivalent) (certifying to B)

CONFLICT OF INTEREST
Do I have a Conflict of Interest*?	Y N If yes, please provide a copy of the Conflict of Interest Management Plan.
Do any members of the investigative team have a Conflict of Interest*?	Y N If yes and a UQ employee, please provide a copy of the Conflict of Interest Management Plan. If yes and external to UQ, a Conflict of Interest Management Plan in line with the Employing Organisation’s framework and the funding provider will need to be provided.

*CONFLICT OF INTEREST
Clause 12.2 of the MRFF Grant Opportunity Guidelines and Clause 7 of the Grant Agreement articulates the Commonwealth’s approach to, and requirements for declaring, managing and notifying Conflicts of Interest. A Conflict of Interest means the Administering Institution, a Participating Institution, a committee member or an advisor, or Personnel working on a Research Activity engaging in any activity or obtaining any interest that would interfere with or restrict the Administering Institution, Participating Institution or Specified Personnel performing a Research Activity fairly and independently. While a conflict may relate to financial interests, it can also relate to other material personal interests, private, professional or institutional benefits or advantages that depend on the conduct of the research or its outcomes. A material personal interest is an interest of a type that can give rise to a real or perceived conflict of interest that could affect the ability of the person to discharge their duties or obligations appropriately. If any parties involved in this project (including participants and organisations) have a conflict of interest in relation to any aspect of the Application, the conflict must be declared to UQ prior to submission. If you later identify that there is an actual, perceived or potential Conflict of Interest or that one might arise in relation to an Application, you must inform UQ in writing immediately, as UQ is required to notify the funding agency. For participants external to UQ, the management of the Conflict of Interest should be agreed with the employing organisation, of which UQ will seek confirmation should the application be successful. Applications from UQ investigators must be consistent with the University’s Conflict of Interest Policy (PPL 1.50.11) and its Responsible Conduct of Research Policy (PPL4.20.02). Where external for-profit partner organisation/s are part of the Application, to help Investigators identify when a conflict of interest is likely to arise, they should consider the following statements: Do I hold a paid or unpaid fiduciary/governance/management role, such as being a Director, of one or more of the external partners on this grant Application? (Actual) Am I a paid employee, such as a Chief Scientific Officer, of one or more of the external partners on this grant Application? (Actual) Do I or a family member/close associate hold shares (equity) in one or more of the external partners on this grant Application that are not publicly traded entities (i.e. listed on the ASX or similar stock exchange)? (Actual) Any of these associations may be incompatible with UQ being able to support the Application.

A. CERTIFICATION BY LEAD INVESTIGATOR
I certify that: All eligibility and other application requirements have been met. I have read and understood the Grant Opportunity Guidelines, including the privacy, confidentiality and disclosure provisions. The proposed project outlined in this application and any associated expenditure has been endorsed by the applicant’s board/ management committee or person with authority to commit the applicant to this project. If the application is funded, the research, including work undertaken by subcontractors and independent contractors, will be carried out in strict accordance with the conditions governing the MRFF Grant Opportunity, including the Grant Agreement and all applicable policies and laws. Any project partners are not included on the National Redress Scheme list of institutions. All project partners and associated activities are in compliance with current Australian Government sanctions. The information contained in this application together with any statement provided is, to the best of my knowledge, accurate, complete and not misleading and that I understand that giving of false or misleading information is a serious offence under the Criminal Code Act 1995 (Cth). I may be requested to provide further clarification or documentation to verify the information supplied in this form and that the department may, during the application process, consult with other government agencies, including state and territory government agencies, about the applicant’s claims and may also engage external technical or financial advisors to advise on information provided in the application. If the application is funded, I agree to participate in the periodic evaluation of the program undertaken by the Commonwealth. I approve the information in the application being communicated to the Department in electronic form. I have met relevant state or territory legislation obligations related to working with children and/or vulnerable persons, and that any person that has direct, unsupervised contact with children and/or vulnerable persons as part of a project under this grant opportunity, has undertaken and passed, a working with children check and/or police check, as required under relevant state or territory legislation. I am also responsible for assessing the suitability of people I engage in this project to ensure children and/or vulnerable persons are kept safe. If the Department is satisfied that any statement made in an application is incorrect, incomplete, false or misleading the department may, at its absolute discretion, take appropriate action. I note such action may include excluding an application from further consideration; withdrawing an offer of funding; using the information contained in the application for a fraud investigation that would be consistent with the Australian Government’s Investigations Standard and Commonwealth Fraud Control Framework and for management purposes and/or terminating any grant agreement between the Commonwealth and the recipient including recovering funds already paid. As the Chief Investigator, I provide written agreement to be named on the application, to participate in the manner described in the application and to the use of my personal information as described in the application’s Privacy and confidentiality provisions. As the Chief Investigator, I confirm that all other researchers named on the application have agreed to participate in the manner described and to the use of their information as described in the application’s Privacy and confidentiality provisions. All personnel contributing to the Research Activity have familiarised themselves with the Australian Code for the Responsible Conduct of Research, the National Statement of the Ethical Conduct of Human Research, the Australian Code for the Care and use of Animals for Scientific Purposes and other relevant policies concerning the conduct of research, and agree to conduct themselves in accordance with those policies. Before the proposed research can commence, all relevant ethical and other clearance/s must be obtained and all statutory requirements must be met. I have notified UQ of all Conflicts of Interest (COI), including material personal interest, that I, and parties involved in or associated with this Application, may have in relation to the Application. I undertake that I will notify UQ of any COIs, including material personal interests, which arise subsequent to the submission. I have prepared this application and will conduct activities under the grant in compliance with UQ policies and procedures. if the application is funded and where applicable, I will abide by the UQ Graduate School conditions for a single UQ centrally-supported Earmarked PhD scholarship.

Signature of Lead Investigator:	Date:
B. CERTIFICATION BY UQ HEAD OF SCHOOL/CENTRE/INSTITUTE
I certify, to the best of my knowledge, that: I agree that the project can be accommodated within the general facilities in my Department, that appropriate facilities will be available, and that sufficient working and office space is available for any proposed additional staff. I agree to have the project carried out in my Department as set out in this application and if successful will contribute the resources outlined in the application and agree that the research be carried out in strict accordance with the conditions governing MRFF research grants, including the Grant Opportunity Guidelines, Funding Agreement, all applicable policies and laws and UQ policy and procedures.

Signature of Head of School/Centre/Institute:	Date:

Name of Head of School/Centre/Institute: