Fogarty Global Health Fellowships NORTHERN/PACIFIC GLOBAL HEALTH RESEARCH FELLOWS TRAINING CONSORTIUM

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1 Last Name: First Initial: Application Due Date: May 14, :00PM ET *May 28 for international applicants Fogarty Global Health Fellowships NORTHERN/PACIFIC GLOBAL HEALTH RESEARCH FELLOWS TRAINING CONSORTIUM ELIGIBILITY This fellowship is open to U.S. post-doctoral trainees and international post-doctoral and doctoral students currently enrolled in health-related doctoral and post-doctoral programs. Persons in health-related disciplines --such as medicine, public health, dentistry, nursing, veterinary medicine, and other health-related disciplines--are eligible to apply. Eligible applicants must be from the consortium universities (Universities of Washington, Minnesota, Michigan and Hawaii) or the consortium s international partner universities in China, Thailand, Kenya, Ghana, Uganda or Peru. U.S. Post-doctoral trainees applying for this Fellowship must: be citizens of the United States or its territories or possessions, or persons lawfully admitted to the United States for permanent residence. Resident aliens must include their green card number in their application. have a demonstrated interest in a career in global health research. be matriculated in a post-doctoral training program at one of the Northern/Pacific Consortium institutions and have obtained endorsement of the application from a mentor at one of the U.S. or international Northern/Pacific Consortium institutions. commit to spending 11 months in the collaborating international country. International doctoral students and post-doctoral trainees applying for this Fellowship must: be citizens of Low- or Middle-Income Countries (LMICs) as defined by the World Bank: have a demonstrated interest in a career in global health research. have the support of a Northern/Pacific Consortium mentor at the LMIC site. They must also have endorsement of the application from a mentor at one of the Northern/Pacific Consortium institutions. NOTE: Preference is given to U.S.-based post-doctoral applicants who have received support from their institution s NIH T32 research training grants, from the Northern/Pacific Consortium s research-oriented global health residency and fellowship training programs or from the prior Fogarty International Clinical Research Scholars and Fellows Program. Competitive trainees from other training programs (e.g., PhD, DVM, DDS) are also eligible to apply. APPLICATION PROCEDURES This is a self-managed application. You are responsible for ensuring all documents listed below are submitted by 3:00PM ET May 14, 2012 (May 28 for international applicants) in order for your application to be considered complete. Application to the Northern/Pacific Global Health Research Fellows Training Consortium requires the following: 1. completion of the Online Application form in its entirety. Completed applications must be submitted by the application deadline via to NPGH- Fellowship@fogartyfellows.org. 2. an NIH Biosketch. Biosketches must be submitted by the application deadline via to NPGH- Fellowship@fogartyfellows.org. For instructions on how to format your Biosketch, please click here. 3. two Letters of Support. Letters must be submitted by the application deadline via to NPGH- Fellowship@fogartyfellows.org. These letters should come from individuals who know you well and address research accomplishments, research potential, and likelihood of a successful research career. For applicants currently engaged in a T32 training program, one letter should be from your Program Director and address permission to obtain a leave-of-absence from the T32 training program if you receive this Fellowship. If applying as an International trainee, one letter of support should be written by a mentor from your affiliated university. These letters should be ed directly by the recommender. TIMELINE* May 14, 2012 Application Deadline Applications that are not complete by May 14, 2012 will not be reviewed. Mid May 2012 Applicants Informed of Results of Initial Review and Program Interviews You will be informed of the results of the initial application review. Selected students will be invited to interview with the local Program Selection Committee at the consortium universities (US applicants only) Early June 2012 Notification of Acceptances All finalist interviewees will be notified of the results of the final review. June 8, 2012 Decisions and assignments finalized August 2012 New Trainee Orientation Program New Trainee participants will participate in a five-day orientation program on the NIH campus in Bethesda, Maryland, USA during which extensive discussion and instruction will take place. Travel expenses will be covered. *Applications from international applicants are due May 28 th. Northern/Pacific Global Health Research Fellows Application

2 General Information ** Please Note: For an application to be considered, every field is required. ** I am a (must be one of the following) Doctoral Candidate and not a U.S. Citizen Post-Doctoral Trainee and a U.S. Citizen Post-Doctoral Trainee and not a U.S. Citizen Current Resident Current Fellow Current Post-Doc Other (please specify) How did you learn about the program? (check all that apply) from mentor/colleague From an alumnus of the FICRS-F Program Internet search (please list site) Dean Other (please specify) Please list the Global Health Fellowship Site you are applying to: Applicant s Name Last First Middle Preferred First Name (if different from First Name above) Present Address Street Apartment Number do not use P.O. Box City State Zip Code Country Telephone Address Permanent Address (if different than above) Cell Home Primary Secondary Street Apartment Number do not use P.O. Box City State Zip Code Country Education INSTITUTION AND LOCATION MAJOR FIELD OF STUDY DATES (TO AND FROM) DEGREE / CREDENTIALS DATE RECEIVED OR EXPECTED Northern/Pacific Global Health Research Fellows Application 2

3 Letters of Support Please provide the following information on the persons who will be providing your letters of support. If applying as a T32 trainee, one letter of support should be written by the Program Director of your T32 training program and specifically address if you would have permission to obtain a leave of absence from your training program if you receive this Fellowship. If applying as an International trainee, one letter of support should be written by a mentor from your affiliated university. Name: Title: Telephone (with country & area codes): Name: Title: Telephone (with country & area codes): Scholarships, Prizes, Awards, and Memberships in Honorary and Professional Societies Please confine your answer to five items. Research Experience Prior research experience would be helpful but is not required to be considered for the program. If you have had formal research experience, including preparation of research protocols or institutional review board applications, please list the institution, laboratory and mentor, and describe the project and your role. Please confine your answer to no more than 300 words. Northern/Pacific Global Health Research Fellows Application 3

4 Research Related Publications Please list publications on which you are an author, as well as posters and presentations you have given at conferences. Please confine your answer to no more than 10 items. Major Extracurricular Interests and Activities Please confine your answer to no more than 150 words. Employment History (starting with the most recent) 1) Organization: Location: Last Position: Dates: (City, State, Country) 2) 3) Previous Experience in Resource-Poor Settings, Domestic or International Please indicate duration and type of activities (i.e. volunteer, research, school related, travel) Please list each experience separately, and confine your entire answer to no more than 200 words. Northern/Pacific Global Health Research Fellows Application 4

5 Personal Statement Please state why you are interested in this program, what you expect to gain from this experience, and what you can offer this program. In addition, please describe how your career goals relate to international health and how this program will contribute to these goals. Please confine your answer to no more than 500 words. Research and Mentoring Plan Please describe your research and mentoring plan: 1) current mentoring and if your current mentor is willing to provide additional mentoring during this Fellowship; 2) a brief description of your area of research interest, research objectives and timeline for applying for institutional review board approvals from U.S. and international institutions; and 3) what areas you anticipate you will require assistance to develop and implement a successful research project. Please confine your answer to 2 pages. Languages While not a requirement for application, do you have a working knowledge of any languages other than English? Please list the language(s) and indicate your knowledge level (beginner, working/conversational and fluent). Northern/Pacific Global Health Research Fellows Application 5

6 Demographic Information The following information is for our administrative purposes only, and will not be shared with the committee reviewing your application. Including this information is completely voluntary. Citizenship Social Security Number (if U.S. Citizen) - - Marital Status Gender Date of Birth Place of Birth (MM/DD/YYYY) City State Country Race/Ethnicity (select your primary self-identification) American Indian or Alaska Native Asian Black or African American Hispanic or Latino/a Native Hawaiian or Other Pacific Islander White or Caucasian Other Racial or Ethnic self-identification (please specify) Northern/Pacific Global Health Research Fellows Application 6