GadjahMada University Regional Training Center for Health Research

supported by WHO-TDR

Course Application Form

2nd Batch of Regional Course on

Implementation Research - IR (Sept26-30, 2016)

Application Deadline: Sponsorship: July26,2016

Target participants(2-3 persons per research team)

1. APPLICANTS INFORMATION

(Please fill in the name exactly as it is in applicant passport)

COUNTRY:

Number of applicant: 2-3 persons

List of applicant

Applicant 1
Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address
Postal Code/ City
Country
Fax
Telephone number including country code
Home Address
Postal Code/ City
Country
Email address
Passport number
Date of birth
Place of birth (city, country)
Present job title
Job description
Knowledge of English / Written: Average___ Good___ Excellent ___
Spoken: Average___ Good__ Excellent ___
Computer literacy / Word: Proficient___ Need Help___ Never Used____
Excel: Proficient___ Need Help___ Never Used____
PowerPoint: Proficient___ Need Help___ Never Used____
Internet: Proficient___ Need Help___ Never Used____
Applicant 2
Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address
Postal Code/ City
Country
Fax
Telephone number including country code
Home Address
Postal Code/ City
Country
Email address
Passport number
Date of birth
Place of birth (city, country)
Present job title
Job description
Knowledge of English / Written: Average___ Good __ Excellent ___
Spoken: Average___ Good __ Excellent ___
Computer literacy / Word: Proficient __ Need Help___ Never Used____
Excel: Proficient __ Need Help___ Never Used____
PowerPoint: Proficient __Need Help___ Never Used____
Internet: Proficient__Need Help___ Never Used____
Applicant 3
Title: Prof/Dr/Ms/Mr.
Family Name
First Name (s) (as in passport)
Organization
Office Address
Postal Code/ City
Country
Fax
Telephone number including country code
Home Address
Postal Code/ City
Country
Email address
Passport number
Date of birth
Place of birth (city, country)
Present job title
Job description
Knowledge of English / Written: Average___ Good __ Excellent ___
Spoken: Average___ Good __ Excellent ___
Computer literacy / Word: Proficient __ Need Help___ Never Used____
Excel: Proficient __ Need Help___ Never Used____
PowerPoint: Proficient __ Need Help___ Never Used____
Internet: Proficient __ Need Help___ Never Used____

2. SUPERVISOR (Name and address of supervisor or head of the institution)

Name:......

Title: ......

Organisation :......

Address : ......

City: ......

Zip code......

COUNTRY ......

Tel :...... Fax......

E-mail :......

3. DESCRIPTION OF PROPOSED RESEARCH

Please provide brief description (max 400 words) covering study title, objectives, design, setting, population, timeframe (start and end) and total budget estimate.

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4. SPONSORSHIP

WHO-TDR through the course organizer offers two types of sponsorship:

  1. full scholarships

For 2-3 groups of SEAR countries which cover course materials, faculty fees, lodging (not applicable for residence of Yogyakarta/GMU staff), lunch and coffee breaks during the course, lumpsumas well as travel expenses (economic airfare) from country of home institution.

  1. Partial scholarships

For 2-3 groupsof SEAR countries which coveronly for course materials, faculty fees, lunch and coffee breaks during the course. Please note that travel, lumpsum and accommodation costs should be covered by individual or their institution.

Attach the following to this application form (can be downloaded in

  • The participants’ typewritten detailed Curriculum Vitae
  • Motivation letter
  • A scanned or copy of participants’ passport.
  • Recommendation letter from supervisor/head of institution.

Send the application package by the deadline (Sponsorship:July26,2016) by fax, e-mail or post to:

Research & Collaboration Unit, Centre for Tropical Medicine 2nd Floor

GedungPAU - UGM, Jl. Teknika Utara, Barek, Yogyakarta 55281, Indonesia

Tel: (+62274) 547147 Fax: (+62274) 547147

Contact Person:

dr. KtutRentyastiPalupi, MPH(Email: )

Failure to provide all of the information requested may result in the rejection of your application.

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