A. Email Your Complete Application As a Single PDF File To

DIRECTIONS:

Applicants are required to submit a two–page research proposal, as well as supplemental materials around their experience and planned mentorship. Candidatesare expected to have spent a significant amount of time preparing this application with the guidance of U.S. and international mentor affiliated with the site.

Note: Fogarty International Center has mandated that 50% of fellowship funding must go to HIV-related research activities so, where possible, applicants in high-prevalence settings should consider how HIV might relate to their work. Please see guidance from the NIH’s research priorities in determining AIDS funding:

A. Email your complete application as a single PDF file to

B. Your mentors/advisors will email their letters of recommendation directly to , too.

ApplicantInformation

FirstName:______MiddleName:______LastName:______

Emailaddress: ______Cell phone#:______

Current Address: ______

City:State:ZipCode:

PermanentAddress: _

City:State:ZipCode:

Current Academic Institution: ______

Current Academic Department: ______

Current Position Title: ______

Terminal Degree:______

Undergraduate Institution: ______grad year______

Master’s Institution: ______grad year______

Medical or Doctoral Institution: ______grad year______

Citizenship (Country):______

Passport #:______U.S. permanent resident INS A#:______

General details about your proposal

In the coming year, we are focusing on training efforts in established sites in the following countries:

• Africa:Democratic Republic of the Congo, Ghana, Malawi, Sierra Leone, South Africa, Uganda, Zambia
• Asia:Bangladesh, India, Thailand, Vietnam
• LatinAmerica:Nicaragua, Peru

U.S. postdoctoral candidates may propose other established research sites affiliated with one of the consortium institutions (UNC, Johns Hopkins, Tulane, Morehouse); however, prior approval is needed.

If applicable, please indicate the following for a proposed academic training site/country not listed above:

Site/Institution: ______

Site Principal Investigator:______

On site mentor:______

Federalwide Assurance (FWA) number:______

Note: you can list an ongoing research project OR original research, you do not have to list both. Please include the title here (writing “see below” is not acceptable.

ForeignLanguage:DoyouhaveaworkingknowledgeofanylanguageotherthanEnglish?

Language(s):______(specify: beginner, conversational, fluent)

Required Letters of Recommendation (LOR)

Recommendations are to be provided separately, and emailed by the author to

1. Prior/currentresearchmentor:

1. LMICbased UJMT FGHFmentor

1. If applicable, a letter from your department chair addressing career trajectory which can include comments on your faculty status. Will you include this or a comparable LOR?

Award requested (check one)

_____Full award (includes stipend, insurance, research and travel)

_____Research and travel only

____ Other: ______

Proposed appointment dates of 12-month traineeship:______

(Note: Fellows are required to spend a minimum of 11 months overseas.)

Title of the T32, D43, or other training program (current or in the last 12-24 months): ______

Program Director:______

Email address:______

Describe prior experience in resource-poor settings, domestic or international

______

______

Demographics

Gender:__ Male

__ Female

__ Prefer not to answer

Ethnic Category:__ Hispanic or Latino

__ Not Hispanic or Latino

__ Prefer not to answer

Racial Category:__ American Indian/Alaska Native

__ Asian

__ Native Hawaiian or Other Pacific Islander

__ Black or African American

__ White

__ More than One Race

__ Prefer not to answer

All components should be single-spaced, with 0.5” margins, and in Arial 11 point font. The page limit for each

section is specified below

1. Research proposal (2 pages): It is expected that applicants review the proposed research design extensively with their primarymentor, who can be U.S. or LMIC based.

i.Specific Aims

ii.Research Plan (overview)

a. Significance

b. Innovation

c. Approach

iii.Timeline for proposed scope of work

iv.Human Subjects (describe the IRB process and timeline for approval)

v.References should be included in the two page limit, if possible- font can be 9pt

2. Budget and budget justification, up to $10,000 for doctoral trainees (1 page)

3. Statement of career goals (1 page)

4. Plan for mentorship over the Fogarty training period (1 page)

5. NIH Biosketchpostdoctoral fellowship ( Pay close attention to formatting, an ill -formatted biosketch reflects poorly on your application.

6. Two to three letters of recommendation emailed directly to

• Required: research mentor letter (previous research)
• Required: International site letter from the site mentor or PI confirming prior communication with

them about their commitment to work with you.

• If applicable, a letter from a supervisor/department chair addressing career trajectory which can

include comments on your future employment status