CDC Short Course. Diabetes Public Health and Research. Application Form CDC’s Division of Diabetes Translation may be able to offer travel expenses for …
CDC Short Course
Diabetes Public Health and Research
Application Form
Please complete the following
I Personal Information
| Last Name: First: |
|Middle: |
|Address: |
|City: State: |
|Zip Code: |
|Country: |
|Telephone: Days Evenings |
|Email Address: |
IIA Qualifying Requirements Yes/No
| | |
|A Are you currently working in public health or a closely | |
|related field? | |
| | |
|B Do you have a masters degree in public health or equivalent| |
|or at
| |
|least 2 years of recent within 5 years experience in public | |
|health? | |
IIB Additional Qualifications Yes/ No
| | |
|A Do you have a MBBS, MD, or PhD degree or have published peer- | |
|reviewed paper? | |
III Educational Background
|Institution |Attendance |Major |Degree |Date Granted |
| |Dates | | | |
| | | | | |
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IV Current Employment
|Organization: Job
Title: |
|Length of Employment: |
|Job Responsibilities: |
| |
|Supervisor: Title: |
|Telephone: Email Address: |
|Street Address: |
V Employment History list previous position covering a maximum of of 10
years
|Dates Employed | Job Title | |
| | |Organization/City State or |
| | |Country |
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? Previous Research Training or Experience
|1 |
|2 |
|3 |
|4 |
|5 |
|6 |
|7 |
VII List 5 Best Publications, Reports, or Oral Presentations
|1 |
|2 |
|3 |
|4 |
|5 |
VIII List Major Honors, Awards, Accomplishments
|1 |
|2
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|3 |
|4 |
|5 |
|6 |
|7 |
|8 |
IX Additional Components
|Each applicant must complete the following component in order to apply to |
|the seminar Use space on next page to complete A, B and C |
| |
|Essay |
|Write a statement on why you wish to attend the course and what you expect|
|to achieve from it Explain how this course will be useful in your current|
|and future work Use designated area for statement 250-word limit |
|Confirmation of Funds/Request for Travel Assistance |
|State how funds will be provided for
travel and accommodation attach |
|letter of support from your sponsor Include at least 2 references from |
|officials in your organization supporting the candidates need for funds |
|and stating how the candidate would benefit from the course CDCs |
|Division of Diabetes Translation may be able to offer travel expenses for |
|a maximum of two candidates, selected strictly on the basis of need; |
|candidates requesting this assistance should explain the following: 1 |
|why they could not find another source of funds; 2 name other sources |
|they have contacted for funds provide letter to confirm; and 3 whether|
|they have approached their employer for support provide letter to |
|confirm |
|Optional not evaluated as part of the application: |
|Describe 250-word limit words a real problem that you are facing while |
|planning, implementing, or improving a diabetes program in your locality |
|From these descriptions, an ad hoc panel of faculty will select 4 problems|
|for discussion and final presentation by work groups to be formed in the |
|short course The public
health importance of the problem will be the |
|major criterion for selection The selection will be independent of |
|acceptance to the short course Feedback will be offered to applicants who|
|were not accepted in the course but whose problems were selected for |
|discussion |
A Essay see guidelines above
B Confirmation of Funds / Request for Travel Assistance see guidelines
above
Optional See guidelines above
All Applications Must Be Sent Preferably Electronically To
Susana Moran
Centers for Disease Control and Prevention
Division of Diabetes Translation
4770 Buford Highway K-10
Atlanta, GA 30341
Phone 770-488-1212
ata2@cdcgov
DEADLINE
APPICATIONS MUST BE RECEIVED BY
July 6, 2006
Source:vitiligosupport.org
