Fogarty International AIDS
Training Program
APPLICATION FOR TRAINING IN AIDS-RELATED RESEARCH
Please answer all questions
completely.
This is an application for training in AIDS-related research with support from a Fogarty International AIDS Training Grant. The Project Director for this grant is Professor Arthur L. Reingold, MD.
This application will be reviewed by Dr. Reingold, Head of Public Health Biology and Epidemiology. If you are applying for academic training (i.e., MPH, DrPH, PhD) you must also submit a formal UCB application, following all instructions for International students as directed in the UCB graduate application.
This application should be typed and all requested information included. The total length of the application, excluding appended materials such as letters of support, curriculum vitae, and sample of previous work, should not exceed 10 pages. The application must be completed in English. Supporting materials may be in English, Spanish, French, or Portuguese.
Applicant Information
Name and title(s):
Home address:
Home telephone #:
(include country
& city codes)
Do you have a FAX number at home?
o Yes ® If yes, is it the same number as your home telephone or different?
o Yes, fax number is the same as the home telephone number
o No If no, what is your home fax number:
o No, I don’t have a fax number at home.
Work address:
Work telephone
#:
(include country
& city codes)
FAX number at work:
(include country
& city codes)
E-mail address:
Country of citizenship:
Country of permanent residence:
Date
of birth: / /
month date
year
City,
State, Province, and Country of Birth:
If
you come to the
o Yes ® If yes, you must complete the following information on dependents who will
accompany you to the
o No ¯
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Name of Dependent |
Relationship to Trainee |
Birthdate of Dependent |
Country of Birth |
Passport # & Expiration Date* |
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If
your dependent(s) will be accompanying you to the
o
My dependent(s) will be entering the
o
My dependent(s) will be entering the
Type of Training Desired (Please check all boxes that apply):
o Academic (MPH) with no previous research experience
o Academic (MPH) with previous research experience
o Advanced academic training (PhD, DrPH)
o Intensive 3-month epidemiology research methods course (3 month stay required [August through October])
o Long-term laboratory training
o Individualized and/or combination training (please specify below):
Duration
of training desired:
List computers and software you are proficient with (i.e., PC or MacIntosh; WP, WP for Windows, MS Word, SAS, STATA, etc.) Please list below all that apply:
For
any type of training requested, you must provide some proof of English
proficiency (i.e., TOEFL). In some cases
if a TOEFL score is not available, we will consider a letter from a
TOEFL
score: Date
taken: / /
month date year
Do you speak any additional language(s) fluently?
o Yes If yes, please list:
o No
Please enclose a curriculum vitae that includes present and past positions held (including your present employment), your education (including any special training in research methods or epidemiology), any awards or honors received, and your publications and/or presentations at scientific meetings.
On a separate sheet of paper, please type
the following information:
• Describe your past experience, if any, in AIDS-related research. Specify your position in any projects that you describe.
• Describe any other research experience you have that would be relevant to your proposed area of research in this application. Specify your position in any projects that you describe.
• Please enclose a written example of your past work that demonstrates your ability. This might be a scientific article, a grant application, a report, or any other written material of which you were the main author.
Have
you been to the
o Yes If yes, when, where and for how long?:
o No
Institutional Affiliation
What organization will you be representing? If this is a large institution, such as a University or a Ministry of Health, please specify what department or branch you will be representing?
What is your position with this organization and how long have you been in this position?
Please enclose a description of your organization, including its experience with AIDS
research and other research that would be relevant to the research proposed in this
application. Describe facilities at your institution or facilities available elsewhere that
would be necessary to conduct the proposed research. If laboratory tests would be
involved, specify where these would be performed.
Proposed Research
On a separate page (or pages), please specify the type(s) of AIDS-related studies you and your organization wish to conduct. We do not expect you to have a fully developed protocol at this time, but we encourage you to be as specific as possible. This statement must be provided for your application to be considered.
Letters of Support
Letters of support will be an important factor in our selection of applicants. In some cases, a letter from one individual may fulfill more than one of the requirements listed below. Letters may accompany this application or may be sent separately. They should be written on official stationery addressed to Arthur L. Reingold, MD. The following is a list of requirements to be fulfilled by letters of support:
A. A senior professional in a position to comment on your potential for research productivity.
B. A senior professional in a different organization able to comment on your potential for public health service to your country.
C. The head of the department or organization you will be representing. This letter must confirm that you will be representing the organization and that the organization wishes to pursue research in the specific area described in this application.
D. Individuals or officials of organizations whose cooperation you would need to successfully complete the proposed research. This might include government, university, or hospital officials, and leaders of the population groups that you would hope to study. In most cases, it should also include a letter from the head of your country’s National AIDS Committee.
• Please include a list of the names, titles, addresses, and telephone numbers of all people who have provided or will provide your letters of support.
Thank you. If you have any questions or if there is any other way we can assist you, please call, write, or fax:
Arthur L. Reingold, MD or Juanita Cook
Division of Epidemiology
140
Telephone: (510) 642-0327
FAX: (510) 643-5163
e-mail: reingold@UCLink4.berkeley.edu
If you are applying for
academic training (i.e., MPH, MS, PhD) through the University of California, Berkeley, School
of Public Health, please note:. . .
You must submit the
Graduate Application for Admission and Fellowships (2005-2006). All materials
including transcripts, letters of recommendation, TOEFL score, and a
non-refundable application fee must be received by the December 1, 2004 posted
deadline. Please visit the
Please include the following materials (listed below) and mail to:
140
• 2
sets of official transcripts (issued by the registrar of each academic
institution attended beyond high
school). Each of the 2 sets of
transcripts must be officially stamped and/or notarized. You must send 2 separate sets of official
transcripts.
• TOEFL (Test of English as a Foreign Language) scores. All international applicants from countries in which the official language is not English are required to take the TOEFL. Send the original copy of the examinee’s score. Photocopies are not acceptable.
The Minimum TOEFL score for admission to the Graduate Division is 570 for paper-based tests and 230 for computer-based tests. The University makes no exceptions!
• If applicable, GRE (Graduate Record Examination) scores not more than 5 years old from the educational testing service. All international applicants whose native language is English and those who have studied for one year or more in schools or universities where English is the language of instruction are required to take the GRE. If you have a doctoral degree (MD or PhD), you do not need to take the GRE.
• 3 letters of recommendation (you do not have to use form G)
• A non-refundable application fee of
$60 (in the form of a U.S. dollar bank check, made payable to the “Regents of the
Deadline for receipt in