DEADLINE DATE FOR RECEIPT OF ALL MD-PhDSTUDENTSHIP APPLICATIONS IS FRIDAY, APRIL 1, 2016at4:00 p.m. APPLICATIONS WILL BE ACCEPTED IF SENT BY OVERNIGHT COURIER ON THE DEADLINE DAY.
As a public body, the Alberta Innovates – Health Solutions (AIHS) is regulated by the Freedom of Information and Protection of Privacy Act (FOIPP) of Alberta. As such, the information on this Personal Data section will be for AIHS internal use ONLY and will not be communicated to anyone outside of AIHS.
SECTION 1: PERSONAL DATA
Name: Surname, First Name, Middle Initial(s)Birthdate:
Year Month Day / Gender: (Check)
Male Female
Permanent Mailing Address: / Phone:
E-mail:
AIHS supports Alberta research institutions in their efforts to promote and ensure the highest standards of research and scholarship practice and behaviour. By his/her signature below, each applicant asserts that this application adheres to all research policies and procedures in place at his/her sponsoring institution, including those regarding integrity in research and scholarship. AIHS reserves the right to confirm this assertion through independent means. AIHS wishes to alert applicants to the consequences of misrepresentation in this application, including misrepresentations of authorship, credentials or research support. In the event of material deviations of the information in this application from reference sources, including citation sources (in the case of authorship), issuing organization(s) (in the case of credentials), or granting agencies (in the case of research support), AIHS reserves the right to disqualify the applicant from the competition in question. Further AIHS actions may include disqualifying the applicant from future AIHS competitions for a time period to be set at AIHS’s sole discretion, withdrawal of any remaining installments of support for any existing AIHS grant or award for which misrepresentation appears in the submission, and seeking partial or full repayment of any past financial support under any AIHS grant or award for which misrepresentation appears in the submission. Further information on AIHS’s support for research and scholarship integrity is found in the Program Guide for the MD-PhD Studentship at
SECTION 2: SIGNATURES The undersigned agree to, and accept, the general conditions governing any award made pursuant to the sponsorship of this application, as set out in the AIHS Guidelines, located at This application may be executed in one or more counterparts, all of which when taken together shall constitute a fully executed version of this application. This application or a counterpart thereof may be executed and delivered by facsimile or electronic transmission and the facsimile or electronic transmission of a signature to another Party or Parties (or to their respective solicitors) shall be of the same force and effect as the delivery of an original signature.
Printed Name / Signature / Faculty/Dept. / DateCandidate:
Primary Research Supervisor:
Co-Supervisor (if applicable):
Co-Mentor:
Career Advisor:
Supervisor’s Primary Department Head/Chair:
Supervisor’s Faculty Dean:
Research Services Office:
1.APPLICANT
A.APPLICANT
Surname, First Name & Middle Initial(s)B.PRIMARY Supervisor
Surname, First Name & Middle Initial(s)C.PROJECT TITLE
D.MD – PhDPROGRAM
1.Indicate what Alberta university you are registered at:2. Indicate the program of study you are currently registered in:
PhD Start Date: xxxx/xx/xx
YYYY/MM/DD
MD Start Date: xxxx/xx/xx
YYYY/MM/DD
3. Department/Faculty registered in:
4. Year 1 of medical school or graduate training completed on: xxxx/xx/xx
YYYY/MM/DD
5. Is the proposed Research Project considered cancer research? YES NO
6. Does the proposed Research Project align with ACPLF priority areas/cancer prevention*? YES NO– If Yes, please fill out Section E.
*Please refer to the AIHS website for cancer prevention definition and ACPLF priority areas. Eligible students will receive an additional $500/year incentive to their research allowance.
APPLICANT NAME
E.CANCER RELATED RESEARCH (if applicable)
Please describe the significance of your Research Project and how it relates to cancer prevention and screening. Describe how the proposed research complements ACPLF priority areas currently in place.
F.ACADEMIC BACKGROUND OF APPLICANT
Please list all current and completed post-secondary programs. Append all university level transcripts.
Degree / University/Institution / Country / Supervisor / Dates of EnrollmentFROM TO (YYYY/MM) (YYYY/MM)
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
G.ACADEMIC INTERRUPTION
Include relevant academic interruptions in your career progress, please provide an explanation indicating the period and reasons for the interruption (i.e. Parental Leave, Bereavement Leave, Sabbatical, Work Experience). Describe how these interruptions have affected your career plan.
APPLICANT NAME
H.RESEARCH AND OTHER RELEVANT WORK EXPERIENCE OF APPLICANT
FROM:(YYYY/MM) / TO:
(YYYY/MM) / Position / Institution/Company/City/Country / Supervisor's Name
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
xxxx/xx / xxxx/xx
I.UNIVERSITY ACADEMIC ACHIEVEMENTS (Prizes, Honors, Awards) (Use additional pages if necessary)
Prizes/Honors/Awards / Awarded By / Local/Provincial/National/International / Year Won/Held
APPLICANT NAME
J.APPLICANT’S ACCOMPLISHMENTS
Outline any relevant academic, leadership, work and/or research accomplishments and/or experiences that have contributed to your career development to date. Contributions described in this section may include academic, non-academic and research achievements. Provide background information on major scholarships or awards and their significance. Do not exceed space below. Publications are to be listed on a separate page, please see application instructions as failure to comply with the instructions may cause a proposal to be deemed ineligible.
Publication list attached? YES NOAPPLICANT NAME
K.APPLICANT’S CAREER DEVELOPMENT PLAN
Describe your career goal(s) and how the above listed achievements, publications, awards and related work and research experiences has prepared you to this point to meet your career aspirations. Also, outline the reasons for undertaking the current program of study as it relates to your career progression, your specific career objectives and how your future career plan(s) will be enhanced by the proposed research training experience outlined in this application.Clearly describe and justify the rationale behind the selection of the mentorship advisors and how the members relate to your career development plan. Do not exceed space below.
APPLICANT NAME
2.LETTERS OF REFERENCE
Identify the three individuals who have been asked to submit a letter of reference on your behalf. The primary research supervisor may be one of the three.Name / Institution/Organization / Email Address
Letters of reference should highlight the applicant’s strengths as they relate to the suitability and experience for the proposed work in this training environment(e.g. originality, technical ability, demonstrated skills, judgment, critical skills, etc.) and the benefit that the proposed experience would provide the applicant towards their career goals.
Append the three confidential letters of reference (in signed sealed envelopes)to the application package.
APPLICANT NAME
3.TRAINING ENVIRONMENT
A.MENTORSHIP ADVISORS
Primary Research Supervisor (Surname, First Name & Initial(s))Complete Mailing Address – (Include Primary Dept/Faculty & Postal Code) / Contact Information:
Phone:xxx-xxx-xxxx
E-mail:
Co-Supervisor (If Applicable) (Surname, First Name & Initial(s))
Complete Mailing Address – (Include Primary Dept/Faculty & Postal Code) / Contact Information:
Phone:xxx-xxx-xxxx
E-mail:
Co-Mentor (Surname, First Name & Initial(s))
Complete Mailing Address – (Include Primary Dept/Faculty & Postal Code) / Contact Information:
Phone:xxx-xxx-xxxx
E-mail:
Career Advisor (Surname, First Name & Initial(s))
Complete Mailing Address – (Include Primary Dept/Faculty & Postal Code) / Contact Information:
Phone:xxx-xxx-xxxx
E-mail:
APPLICANT NAME
- Biographical Sketch Information Form
Provide the following information for each Mentorship Advisor listed in Section 3 – Training Environment, including the primary research supervisor and co-supervisor (if applicable), co-mentor and career advisor. A maximum of four pages (excluding this information cover page) may be submitted for each. NOTE: Only the first four pages, along with this information cover page, will be included for each biographical sketch.
NAME and MENTORSHIP ROLE (Primary Research Supervisor, Co-Supervisor, Co-Mentor, Career Advisor) / INSTITUTION/ORGANIZATION AND POSITION TITLECOMPLETE MAILING ADDRESS
EDUCATION / TRAINING / RELEVANT WORK EXPERIENCE (List only work experience relevant to the proposedresearch activities)
Institution and Location / Degree
(if applicable) / Year / Field of Study
Primary Research Supervisor and Co-Supervisor (if applicable): please provide additional information according to
allheadings, A through E.
Co-Mentor and Career Advisor: please provide additional information according to headings A, D and E. Headings B and C may also be included, as appropriate.
A maximum of four pages (excluding this information cover page) may be submitted for each.
- Peer-Reviewed Publications(not required for non-academic sectors).List published or accepted publications only. Do not list those that are in preparation or submitted. List only the most recent and/or relevant publications (last 5 years). Please indicate (i.e. underline, bold, or asterisk) any authors that were/are your trainees.
- Other Outputs Relative to the Training Environment Activities. This may include government reports, clinical practice guidelines, patents, knowledge exchange activities, etc.
- List all currently active and/or pending operating research grants only. Do not list equipment-related or research allowances associated with studentship or fellowship awards. Please specify if you are the principal or co-investigator, and identify only the portion of the funding you receive.
- Current trainees and/or staff, and indicate level of training and expected completion dates. For non-academic sectors, please list current staff that you manage and give a short description of their roles.
- Relevant honours, awards, recognitions related to research, mentoring and/or teaching.
APPLICANT NAME
4.RESEARCH TRAINING ENVIRONMENT
Primary Research Supervisor to Discuss the Training Environment and the Role of Trainee in the Proposed Research Project. Describe in specific detail the resources available to support the applicant’s research and the broad training opportunities the environment provides. Outline the benefit for the applicant training in this environment, highlighting the facilities, and other personnel the trainee will have the opportunity to interact with.Detail the role of the trainee in the proposed research project and how it links to the supervisor’s research program and/or research group.Do not exceed space below.
APPLICANT NAME
- MENTORING PLAN
The Primary Research Supervisor and Co-Mentor TO DISCUSS MENTORING ENVIRONMENT.
Describe in detail how the proposed mentorship advisors will benefit the research training, and career and professional development of the applicant. Provide information regarding the specific plans for the interactions of the mentorship advisors and the trainee. Please include how the Mentoring Plan will address the activities, knowledge, skills and abilities required by the applicant to achieve the goals set out in the Career Development Plan. Do not exceed space below.
APPLICANT NAME
PROJECT TITLE
- SIGNIFICANCE AND RELEVANCE SUMMARY
Provide a summary of the proposed research activities in non-scientific, everyday language that would be accessible to a general audience and clearly communicates the significance and relevance of the proposed research activities. Use analogies, simplifications, and generalizations rather than scientific and technical terms. Do not exceed the space below. Please Note:This section may be provided to a diverse set of stakeholders, including the public.
APPLICANT NAME
- PROPOSED RESEARCHPROJECT
The applicant is to provide a detailed description of the proposed research project for the period during which the award is to be held. Background information should indicate the position and significance of the proposed research within the context of the current knowledge of the field. The research plan outlining the proposed project should state the specific objectives; outline the methodological approach; and the defined key milestones or deliverables to be achieved. Do not exceed space below.Only references related to the project description are to be listed on a separate page.
Application - 1MD - PhD Studentship 201604