Application Form Global Health Institute - Thailand 2015 Researchers Conference of “Emerging disease at convergence of animal, human and environment health” Faculty of Veterinary Medicine, Chiang Mai University, Thailand 2nd – 20th February, 2015 ComAcross - One Health in Asia 1. Information of Participant *Given name *Last name *Preferred Written Name *Organization *Country *Contact Number *Email Address *Type of organization □ Industry □ Government Sector □ University/ Educational Institute □ Student □ NGOs *Professional □ Medical □ Food Science □ Veterinary □ □ □ Social Science Economic Other 1 2. Please see the details of offered courses in GHI 2015; WEEK 1 2 – 6 FEB WEEK 2 9 – 13 FEB Pre-conference: Training Course Course1: Global Health Leadership: the convergence at animal, human and the environment 5 days (2 -6 Feb) Conference: “Global Health Conference for Researchers in emerging disease at the convergence of animal, human and environmental health” Emerging and Reemerging diseases Antimicrobial resistance Application of risk analysis Epidemiological tools and application Food safety and hygiene One Health Education for Asia Course 2: The Global Burden of antimicrobial resistance 3.5 day (3 - 6 Feb) Course 3: Participatory Epidemiology Approach to One Health – EcoHealth (Introduction) 5 days (2 -6 Feb) Course 4: Environmental Health 5 days (2 – 6 Feb) WEEK 3 16 – 20 FEB 4 days Post-conference: Training Course Course 5: Farm to table field study 5 days (16 – 20 Feb) Course 6: Food safety risk analysis 5 days (16 – 20 Feb) Course 7: Epidemiological, economical and ecological components for One Health 5 days (16 – 20 Feb) Course 8: Introduction to GIS 5 days (16 – 20 Feb) Course 9: Participatory epidemiologic approaches to One Health – EcoHealth 2 (Community Base) 5 days (16 – 20 Feb) REMARK: At least 10 participants are needed per course. We have right to cancel the course which has less 10 participants. Eligible for academic credit Package Detail Package A Conference + Pre and Post conference courses Package B Conference + 1 Pre conference course Package C Conference + 1 Post conference course Conference only Training course only 2 3. *Which package do you prefer? □ Package A □ Package B □ Package C □ Conference only □ Training course only If you select training course, please specific your preference. 4. Please specific the other 3 most preference courses in case your selected course are closed due to less 10 participants by putting digit 1-3 in front of the offered course. (1 = most 2 = fair 3 = weak) Pre-Conference week (2-6 February 2015) Course 1: Global Health Leadership: the convergence at animal, human and the environment Course 2: The Global Burden of antimicrobial resistance Course 3: Participatory Epidemiology Approach to One Health – EcoHealth (Introduction) Course 4: Environmental Health Post-Conference week (16-20 February 2015) Course 5: Farm to table Course 6: Food safety Risk analysis Course 7: Epidemiological, Economical and Ecological Components for One Health Course 8: Introduction to GIS Course 9: Participatory epidemiologic approaches to One Health – EcoHealth 2 (Community Base) 5. Conference (9-13 February 2015) □ Oral Presentation □ Poster Presentation 3 6. Food Restriction 7. Special Request -Thank you very much- Please send the filled out application form to Email: vphcap@gmail.com or Fax: (66) 053-94 8072 Attn: Ms. Warisara Sukumolchan 4