2018IPOS Research Training Academy

Scholarship Application

Please type in ENGLISH.

Family name(as it appears on your passport):
First name:
Profession:
Title:
Degree:
Work address:
Name of Institution:
Department:
E-mail:
Passport Number:
Passport Expiry date:
Sex: / MALE FEMALE
Date of birth:
Place of birth:
Country of citizenship
Telephone number:
Current full home address:

All personal information provided is treated as confidential and will be shared only with the Scholarship selection committee and CRDF Global.Please note according to US grant regulations, awardsmust not be made to parties listed on the government wide exclusions in the System for Award Management (SAM). Therefore, this system will be checkedbefore issuing an award.Only your name, city, country, and place of work will appear in this Training Academy’s final report. Number and amount of scholarships will depend on funding.

Please answer the following questions:

YOUR WORK:

  1. Please circle your level of psycho-oncology knowledge

BEGINNERINTERMEDIATEADVANCED

  1. Please circle your level of research knowledge

BEGINNERINTERMEDIATEADVANCED

  1. Have you ever conducted research in the past? YES NO

If so, please describe:______

  1. Do you currently conduct research? YES NO

If so, please describe: ______

  1. Do you offer clinical psycho-oncology services to cancer patients? YES NO

(If NO, skip to Q. 9)

If YES - In your role as a psycho-oncologist providing clinical services to cancer patients:

  1. Who are your patients (check all that apply):

____Adults ___Children ___Family members

  1. How many cancer patients do you see in a year? ______
  1. What types of cancer do you see in your patients? ______
  1. What services do you provide to your patients? ______
  1. What types of consultation or teaching do you do with staff in your institution around psycho-oncology issues? ______
  1. Approximately how many students (medical/nursing/psychologist/social work) do you teach in one year? ______
  1. How many psycho-oncologists are there at your hospital or institution in total? ______
  1. What other disciplines (medicine, nursing, social work, psychology, psychiatry, occupational therapists etc.) do you work with in providing psychosocial care? ______
  1. Do you have an appointment at a university in your professional role? YES NO
  1. If yes, are you on the Curriculum Committee at your university? YES NO

EDUCATION: Please list your educational experiences and degrees below starting with the most recent:

Name of University or College / Major or Area of Concentration / Degree Received / Year Degree Received
(example) / Harvard University / Psychology / B.A. / 1990
Undergraduate Education
Graduate Education (list Master’s and Ph.D. study on separate lines)
  1. If applicable, please list any extenuating circumstances (i.e., leave of absence from work for maternity/paternity, sickness, etc.) that explain a delay of more than 6 years since completion of your training:

Extenuating circumstance / Dates
  1. If you have taken any post-college courses in Psycho-Oncology or related courses relevant to your work in Psycho-Oncology, please list below:

Course Subject / Where Taught / Taught by / Length of Course
  1. What is your level of proficiency in English? BASIC - INTERMEDIATE - ADVANCED
  2. Have you in the past received a scholarship to attend an IPOS Academy? YES NO

INTEREST IN ATTENDING THE IPOS 2018 RESEARCH TRAINING ACADEMY:

  1. What motivates you to attend this Psycho-Oncology ResearchTraining Academy? (no more than 100 words)

______

  1. How will you use this new research knowledge? (no more than 100 words)

______

  1. Please describe aresearch project you would be interested in developing (no more than 100 words):

______

______

  1. Are you able to attend the entire 3 days Training Academy in Hong Kong (October 28-30)? YES NO
  2. Provided IPOS secures funds, are you able to attend the entire 3 days of the IPOS Congress in Hong Kong (October 31-November 2)? YES NO
  3. Are you a member of the International Psycho-Oncology Society (IPOS)? YES NO
  4. Are you a member of your National Psycho-Oncology Society? YES NO

IPOS SCHOLARSHIPS FOR THE IPOS 2018RESEARCH TRAINING ACADEMY:

Please provide a brief summary of how you hope to achieve the following:

  1. Community Outreach: describe how you plan to develop your own country’s research programs in psycho-oncology (no more than 100 words)

______

  1. What elements of your research environment (research activity, resources and infrastructure - such as internet access, to databases, to scientific articles, to start-up funds - and mentorship) will contribute to the quality of your future research training experience?

______

  1. Barriers: describewhat you anticipate will be the main barriers to developing and implementing your research project in your current setting, and your plan to overcome these barriers.(no more than 100 words)

______

______

Note: Please note that travel arrangements and accommodations will be organized by IPOS for recipients of the NCI Travel Scholarship. There will be no possibility of extending or altering these plans.

Note: It is the responsibility of the applicant to ensure the application is complete. Incomplete applications or handwritten applications will be automatically withdrawn from the contest without notice. Applications will only be accepted if they are received at your earliest convenience beforeJune 22, 2018 to the following e-mail address: . Applications must include the fully completed Application Form, a five-page Curriculum Vitae for the applicant, and a Copy of his/her Passport valid for travel to Hong Kong during the Academy.

Note:Please send any questions you may have about this call for applications to the following e-mail address: . IPOS will only be available to answer any questions related to this call for applications from May 17, 2018 to June 7,2018, after which IPOS will no longer be able to answer. After June 7, 2018, the next correspondence the applicants will receive is the result of the competition. Participants should anticipate receiving the results by the first week of August. If you have not received a response, please check the IPOS website to know if there has been a delay in the processing of the applications. If you have not received a letter of offer by the first week of August, unless otherwise indicated on the IPOS website, it means that you were not selected for the scholarship.

HOW TO SUBMIT THE APPLICATION?

Please email your Scholarship Application Form including the check list below, a current copy of your Curriculum Vitae (CV) in English and a copy of your passport no later than June 22, 2018 to the following email: SE NOTE THAT APPLICATIONS WITHOUT A 5-PAGE CV AND COPY OF PASSPORT WILL NOT BE ACCEPTED.

Check list for the IPOS RTA application

Please confirm by checking the boxes that you meet the eligibility criteria below, and sign at the end of this page.

I am a professional within completion of my academic training and establishment of my independent career (i.e., within 6 years of completion of my academic training);

I am based in and conduct my research in LMIC in a clinical or academic field appropriate to the field of psycho-oncology (e.g., physicians, nurses, psychologists, social workers, epidemiologist);

My country of residence is in Low-income and lower-middle income countries as defined by the World Bank:

I am fluent in oral and written English;

I am providing a photocopy of a national passport from the country of residence valid for the required period after departure from Hong Kong (November 3rd 2018) – Please check with your appropriate embassy or consular authority to ensure your passport is valid for the required period;

I have no known criminal record;

If this is required (depends on the country of residence see link below), I commit to obtain a Visit/Transit Visa from Hong Kong and show proof of this valid Visa to IPOS at least 2 months before the RTA (before August 28th, 2018)

You can find the Visa form here:

I am eligible to obtain a Visa from Hong Kong if a Visa is required:

I commit to attend the three-day Research Training Academy on October 28-30 if selected to obtain a NCI Travel Scholarship;

Provided IPOS fundraising is successful, I commit to attend the three day IPOS Congress in Hong Kong (on October 31-November 2) as well as specific events within this congress as mandated by the RTA Organizing Committee:

I commit to developing a research project during the Research Training Academy and present it briefly in a 15-min presentation on the last day of the Academy;

I commit to being mentored during 6 meetings over one year by an IPOS researcher for continued scientific support in implementing a research project;

I understand that the Scholarships will comply with the Fly America Act, which will require that all domestic and international travel funded be purchased from a US-flag air carrier. The Fly America Act applies to any segment of a trip where a US-flag carrier is an available option;

I am opened to share a hotel room in double occupancy during the Research Training Academy and Congress (with same sex pairing).

______

Signature of applicant

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