2017-2018 Application
Doctoral Students (MD, PhD, or Equivalent) from US and Low- and Middle-income Countries
DIRECTIONS:
Applicants are required to submit a two-page research proposal, as well as supplemental materials around their experience and planned mentorship. Candidates are 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 applicable, 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: https://grants.nih.gov/grants/guide/notice-files/NOT-OD-15-137.html
A. Email your complete application as a single PDF file to
B. Your mentors/advisors will email their letters of recommendation directly to too.
Applicant Information
First Name: ______Middle Name:______Last Name:______
Email address: ______Cell phone#:______
Current Address: ______
City: State: Zip Code:
Permanent Address: _
City: State: Zip Code:
Current Academic Institution: ______
Current Doctoral Program: ______
Pending degree type (e.g. MD, PhD etc)______
Undergraduate Institution: ______Degree:______grad year:______
Master’s Institution: ______Degree: ______grad year:______
Citizenship (Country):______
Passport #:______
U.S. permanent resident INS A#:______
General details about proposal
For doctoral students, we are focusing on training efforts in established sites in the following low- and middle-income countries (LMICs). International candidates must be a citizen or permanent resident of the host country.
· Africa: Democratic Republic of the Congo, Ghana, Malawi, Sierra Leone, South Africa, Uganda, Zambia
· Asia: Bangladesh, India, Thailand, Vietnam
· Latin America: Nicaragua, Peru
How did you learn about the UJMT Fogarty Global Health Fellows Program?Area of research interest
Proposed LMIC training site (institution name and country):
Mentor at LMIC training site
Mentor at US-based institution
Research project in progress that you intend to work on (attach the project methodology, IRB approval # and dates, PI biosketch, describe your role)
Original research proposal title (attach a 2-page research proposal).
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)
Foreign Language: Do you have a working knowledge of any language other than English?
Language(s):______(specify: beginner, conversational, fluent)
Required Letters of Recommendation (LOR)
Recommendations are to be provided separately, and emailed by the author to
1. Proposed US mentor:(required)
Institution
Title
Email:
2. Proposed international mentor:*
(required)
Institution
Title
Email:
3. Do you plan to submit a letter from a past research mentor, dean, or department chair?
(optional) / Yes____ No____
Name
Title
Email:
4. Do you propose co-funding from another research or training program? If so, please include letter outlining the level and duration of support from the PI or director. / Yes____ No____
Name
Title
Email:
* International mentor must reside full-time at the research site.
Award requested (check one)
_____Full award (includes stipend, insurance, research and travel)
_____Research and travel only
_____Other: ______
Proposed appointment dates of FGHF 12-month fellowship:______
(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
PROJECT PROPOSAL INSTRUCTIONS: PLEASE READ CAREFULLY
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 primary mentors, both from the US and from the international site.
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 provided but will not count towards the two-page limit
2. Budget and budget justification (1 page): Up to $7,000 for doctoral trainees
3. Statement of career goals (1 page)
4. Relevance of work to US research and global health priorities (0.5 page)
5. Plan for mentorship (1 page): This should include specific areas of mentorship and frequency of meetings/calls with members on the mentorship committee
6. NIH Biosketch for predoctoral fellows: Pay close attention to formatting, a poorly formatted biosketch may reflect affect on your application. https://grants.nih.gov/grants/forms/biosketch.htm
7. Letters of recommendation: Up to four letters; should emailed directly to
· US mentor’s letter (required)
· International mentor’s letter (required) – this mentor should be living and working full-time at the site
· Previous research mentor (optional) – if no previous research mentor, a letter from the dean or department chair addressing your academic research goals and accomplishments may be submitted
· Program co-funding (if jointly supported with another grant) – if the applicant has secured co-funding from another training program (e.g., T32 program) or grant, a separate letter from the PI or director should be included outlining the amount and duration of this support