Training Module. Canadian Institutes of Health Research. Instituts de recherche en santé du Canada. Candidate. Proposed Start Date (MM/YYYY)

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1 Canadian Institutes of Health Research Instituts de recherche en santé du Canada Training Module Program(s) CIHR Rx&D* SME* Doctoral Research Award Fellowship Operating Fellowship Senior Research Fellowship (Phase 1)** Clinician Scientist (Phase 1)** New Renewal * A letter of intent to CIHR must precede submission to these programs. ** These programs require nomination by a Canadian Institution. Partnership Programs For CIHR Use Only Michael Smith Award PROTECTED WHEN COMPLETED Proposed Start Date (MM/YYYY) Competition Date: Have you applied to this program in the last two years? Yes No Candidate Surname Given Names Citizenship: Canadian Permanent Resident Other 1 Primary Supervisor: 2 Co-Supervisor (if applicable): Surname Given Names Location where research will be conducted Institution / Organization Period of support requested: Language in which proposal is written Years Months English French Faculty / School Descriptors: Provide up to 10 keywords to describe this research project. Department Institution which will administer the funds Project Title Do you agree to the release of the information on pages 1, 6 and 7 (proposed training program) for the purpose of determining potential eligibility for other sources of funding either within CIHR budgets for strategic research or from other organizations? Yes No It is agreed that the general conditions governing Grants and Awards as well as the statements The Meaning of Signatures on Application Forms as outlined in the Canadian Institutes of Health Research Grants and Awards Guides apply to any grant or award made pursuant to this application and are hereby accepted by the candidate and the candidate's institution. Signatures Candidate Primary Supervisor and Co-Supervisor (if applicable) Head of Department at Proposed training location Date: Name: Date: Name: Date: Training Module, Page 1 (2004)

2 Information Page to be completed by candidate: FOR ADMINISTRATIVE USE ONLY. The information on this page will not be used in the evaluation of the application. Strategic Initiative/RFA Industrial Partner(s) Partnership Program Special Program Institute Research Priority (with its sponsoring Institute) Areas of Research Primary Secondary Classification Codes Primary Secondary Suggested CIHR Institute(s) Select a primary CIHR Institute whose research mandate is related to this application s research area(s) and objective(s). Indicate a second, third and fourth CIHR Institute only if the substance of this grant / award application significantly overlaps with the research mandate of an additional Institute. First Choice Second Choice Third Choice Fourth Choice Themes Indicate a primary theme classification by typing in the number 1 next to the selected theme. Indicate a second, third and fourth theme classification only where the substance of this grant / award application significantly overlaps more than one theme (use numbers 2, 3 and 4 to indicate the selections in order of importance). Biomedical Research Clinical Research Research respecting health systems and health services Research on societal, cultural and environmental influences on health and the health of populations Indicate if the project involves: Human Subjects Yes No Animal Experimentation Yes No Human Stem Cell Research Yes No Training Module, Page 2 (2004)

3 Degree in progress Degree Type Degree Name Department Institution Start date MM/YYYY Expected date of completion MM/YYYY Qualifications, certificates and licenses in progress Start date MM/YYYY Expected date of completion MM/YYYY With this award, are you proceeding or planning to proceed to any additional degree, diploma, speciality certification? No Yes (please specify) Degree sought Degree Type Degree Name Department Institution Start date MM/YYYY Expected date of completion MM/YYYY Sponsors Candidates must ask three individuals to provide assessments on their behalf using the appropriate CIHR forms. Additional assessments will not be considered. These should include (if applicable) assessments from each of your two most recent research supervisors. For Postdoctoral and Senior Research (Phase 1) Fellowship candidates, one of these assessments should be from your PhD supervisor (if applicable). Give the names of the individuals whose assessments accompany this application. 1. Name of Sponsor / Relationship to Candidate Current Position Held Institution Training Module, Page 3 (2004)

4 Training Expectations (one additional page may be added) Fellowship and Senior Research Fellowship: Provide an overview of how your previous research training relates to the present proposal and elaborate on your career goals. Describe how the training you expect to acquire will contribute to your future research achievements and productivity and how this award will enable you to establish yourself as an independent investigator. In addition, if you are planning to hold this award in the same institution where you completed your PhD, please justify. Training Module, Page 4 (2004)

5 Lay title of research (one line only) Abstract (suitable for preparation of a press release) Provide, in 15 lines or less, a non-technical summary of your research, written in simple and clear language suitable for a lay audience. The summary should indicate how your research, ultimately, can improve personal health, the health of populations and/or the health delivery system. Training Module, Page 5 (2004)

6 Proposed Training Program This section should be completed in collaboration with the proposed supervisor. Both the candidate and the proposed supervisor must sign on page 8 to confirm the accuracy of the proposed training program. a) Project Title b) Summary of the research project. Include specific hypothesis of research and describe the candidate s role on the project. This summary should be written in general scientific language. For Doctoral Research Awards and Fellowships no additional pages may be added. For Clinician Scientists (Phase 1), Senior Research Fellowships (Phase 1) and Operating Fellowships, a minimum of 3 pages and maximum of 6 pages are required. Page limits include references. Training Module, Page 6 (2004)

7 c) Describe the space, facilities and personnel support which will be available to the candidate. No additional pages may be added. d) Describe all activities to be undertaken by the candidate other than direct work on the proposed research project (i.e. teaching, courses, supervision, seminars, clinical activities). Indicate the percentage of time to be spent on each activity using whatever timeframe (per week / month / year) that best describes the involvement. The summary of the research project was written by: Candidate Proposed Supervisor(s) Both The undersigned agree that this accurately describes the training program proposed. Primary Supervisor Co-Supervisor Candidate Training Module, Page 7 (2004)

8 APPENDICES (check the appropriate boxes) For the program to which you are applying, append the following documents. NOTE: Sponsors assessments and transcripts must be provided in an envelope, sealed at the source and preferably included with the application. Doctoral Research Award 1. Three sponsors report forms (Rating form and explanation of ratings) 2. Transcripts (including undergraduate transcripts) 3. Copy of permanent resident document (if applicable) Fellowship and Operating Fellowship 1. Three sponsors assessment forms (Rating form and letter of support) 2. Transcripts (graduate and / or health professional training) 3. Copy of permanent resident document (if applicable) 4. Letter from proposed supervisor for foreign candidates 5. Proof of Canadian licensure (if applicable) Senior Research Fellowship (Phase 1) 1. Three sponsors assessment forms (Rating form and letter of support) 2. Transcripts (graduate and / or health professional training) 3. Copy of permanent resident document (if applicable) 4. Proof of Canadian licensure (if applicable) 5. Letter of support from Dean of nominating Institution Clinician Scientist (Phase 1) 1. Three sponsors assessment forms (Rating form and letter of support) 2. Transcripts (health professional degree and/or graduate research training) 3. Copy of permanent resident document (if applicable) 4. Proof of Canadian licensure 5. Letters of support from nominating Institution a) from the Dean b) from the Head of the Department 6. Letter from the candidate List the names of the individuals providing letters Training Module, Page 8 (2004)

9 All sponsors listed on page 4 of the CIHR Training Module must provide an evaluation of the candidate using the appropriate form: Doctoral Research Award Industry Partnered Studentship Fellowship: Operating Fellowship Senior Research Fellowship (Phase 1) Clinician Scientist (Phase 1) Sponsor s Report on a Candidate for a Doctoral Research Award: a) Rating Form b) Explanation of Ratings Sponsor s Assessment of a Candidate for a Research Training Program a) Rating Form b) Letter of Support Sponsor s form Module, Page 9 (2004)

10 Canadian Institutes of Health Research Instituts de recherche en santé du Canada SPONSOR S ASSESSMENT OF A CANDIDATE FOR A RESEARCH TRAINING PROGRAM (NOT applicable to Doctoral Research Awards) THIS EVALUATION CONSISTS OF TWO PARTS: (A) Rating Form (B) Letter of Support BOTH MUST BE COMPLETED. The information provided on this form is most important to CIHR in evaluating the suitability of the candidate for training in research in the health sciences. You are therefore asked to give detailed information (both pro and con) about the candidate. The Canadian Privacy Act stipulates that, in response to a specific request by the candidate, CIHR must make available a copy of your assessment. (A) Check the boxes that most nearly represent your opinion of the candidate in comparison with a representative group of individuals you have known who have had approximately the same training and experience. (B) The letter should be typed in black as the material must be duplicated for the peer review process. The assessment form and the letter are to be returned, in a sealed envelope, to the candidate who in turn will enclose them as part of his / her Award application. Candidates need your support to ensure that the material is returned to them in a timely manner to complete their application package. CIHR will not consider later or incomplete applications. A. Exceptional Excellent Very Good Good Acceptable Upper 2% Upper 10% Upper 15% Upper 20% Upper 33% Upper 50% Lower 50% Background preparation Industry / perseverance Motivation / Initiative Organizational ability Skill at research (demonstrated) Skill at research (potential) Judgement / critical sense Intellectual ability Originality (demonstrated) Originality (potential) Interpersonal skills Supervisory skills Independent research (potential) Independent research (demonstrated) Name of Sponsor and Relationship to candidate Unable to judge Signature of Sponsor Date Sponsor s Report on a Candidate for a Research Training Program, Page 10 (2004)

11 Canadian Institutes of Health Research Instituts de recherche en santé du Canada B. SPONSOR S LETTER OF SUPPORT FOR CANDIDATE (To be completed by the sponsor not applicable to Doctoral Research Awards) AS WELL AS COMPLETING THE RATING FORM, PLEASE PROVIDE A LETTER TO THE CIHR INDICATING THE FOLLOWING: the period of time and in what capacity you have known the candidate; relative to others having the same training, what is your overall assessment of the candidate; elaborate on the candidate s performance during research and / or clinical training. Give specific examples of behaviour to support your ratings on the assessment form. Additional pages may be added if necessary. (Max 2 pages) Name of Sponsor Position / Department / Institution Signature of Sponsor Date (If you prefer to print part B on plain paper, please ensure that the name of the candidate appears at the top of the page with your signature and the date at the end. Part B must not exceed two pages) Sponsor s Report on a Candidate for a Research Training Program, Page11 (2004)

12 Canadian Institutes of Health Research Instituts de recherche en santé du Canada Training Module Canadian Institutes of Health Research Instituts de recherche en santé du Canada ACKNOWLEDGEMENT TO THE INDUSTRIAL PARTNER (if applicable) This will acknowledge receipt of the application of Acknowledgement to be sent to the company contact person (Give name and a mailing address) Program Applied for: Canadian Institutes of Health Research Canadian Institutes of Health Research ACKNOWLEDGEMENT TO THE CANDIDATE Instituts de recherche en santé du Canada This will acknowledge receipt of your application. Acknowledgement to be sent to: (Give name and a mailing address) Program Applied to: Canadian Institutes of Health Research Training Module, Acknowledgement Page 12 (2004)