GADJAH MADA UNIVERSITY REGIONAL TRAINING CENTER FOR HEALTH RESEARCH SUPPORTED BY WHO-TDR

Course Application Form2nd Batch of Regional Course on

Implementation Research - IR (Sept 26-30, 2016)Application Deadline: Sponsorship: July 26, 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 1Title: Prof/Dr/Ms/Mr.Family Name

First Name (s) (as in passport)Organization

Office AddressPostal Code/ CityCountryFax

Telephone number including country codeHome AddressPostal Code/ CityCountryEmail address

Passport numberDate of birthPlace of birth (city, country)Present job title

Job description

Knowledge of English Written: Average___ Good___ Excellent ___Spoken: Average___ Good__ Excellent ___

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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 2Title: Prof/Dr/Ms/Mr.Family NameFirst Name (s) (as in passport)Organization

Office Address

Postal Code/ CityCountryFaxTelephone number including country codeHome AddressPostal Code/ CityCountryEmail addressPassport numberDate of birthPlace of birth (city, country)Present job titleJob 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 3Title: Prof/Dr/Ms/Mr.Family NameFirst Name (s) (as in passport)Organization

Office Address

Postal Code/ CityCountryFaxTelephone number including country codeHome Address

Postal Code/ CityCountryEmail address

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Passport numberDate of birthPlace of birth (city, country)Present job titleJob 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, lumpsum as well as travel expenses (economic airfare) from country of home institution.

2. Partial scholarshipsFor 2-3 groups of SEAR countries which cover only 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 http://retrac.fk.ugm.ac.id): 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: July 26, 2016) by fax, e-mail or post to:

Research & Collaboration Unit, Centre for Tropical Medicine 2nd Floor Gedung PAU - UGM, Jl. Teknika Utara, Barek, Yogyakarta 55281, IndonesiaTel: (+62274) 547147 Fax: (+62274) 547147

Contact Person: dr. Ktut Rentyasti Palupi, MPH(Email: ktutasti@gmail.com)

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

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