Revised December 20, 2012

Face Page…………………………………………………………………
Biographical Sketch
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Study Site (s), Cultural Experience……………………………………..
Research Plan…………………………………………………………….
Human Subjects Review…………………………………………………
Personal Health and Safety Assessment
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Letters of Recommendation……………………………………
Release and Ind emnification……………………………………………
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1.
Title of Research Proposal
Name of Applicant (Last, first, middle initial): Degree Candidacy, School, and Year:
Dates of proposed award:
From (MM/DD/YY) to (MM/DD/YY)
Estimated Transportation Costs:
Place of Birth (Town, State/Province, Country)
Name of Yale sponsor:
Department:
University Address
Telephone
Fax
Email address
Name of overseas sponsor:
Institution
Address
Telephone (country code, city code)
Fax
Email address
APPLICANT CERTIFICANTION AND ACCEPTANCE: I hereby certify that the statements herein are true and accurate to the best of my knowledge, and I agree to comply with the CIH terms and conditions if an award is issued as a result of this application.
__________________________________ ________________________________
Signature Date
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Education
Institution and location
Previous Experience Abroad
Country
Degree confirmed / Date
Inclusive Dates
Field of study
Purpose (2-3 words)
Foreign Language(s) spoken Degree of competency: Speak Listen Write
Research / Community Activity in College / Graduate School (use bullet points)
Present Career Objectives (200-300 words)
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Courses taken relevant to research project
Briefly describe why your experience and qualifications make you particularly suited for your role in this project (200-300 words)
Description of Cultural Experience
Each project is judged by its relevance to the health needs of the host country, its design, its feasibility, and the extent to which the experience will enhance the cultural outlook of the student. Although the quality of the research is of great importance, the Downs Fellowship is also intended to provide a new and unique cultural experience through research abroad.
Describe what you hope to gain from this experience (400-600 words).
Performance Site Description
Indicate the foreign site where the work described in the Research Plan will be conducted.
Describe the scientific resources available at this site to conduct your proposed study and why this place may be appropriate or unique for this work (100-300 words)
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Estimated Budget
Item
Travel
Transfer to/from airport
Local ground transportation
Food/ Lodging
Lodging
Food
Research
Telecommunication
Office supplies (pen, paper)
Translation (if needed)
Research equipment
Recruitment related expenses
Other
Total
Amount Source of funding
(Personal, Downs, YSM OSR, Other)
Abstract
Summarize your proposal, making sure that you include the overall goals of your study, and how your project will contribute to the advancement of science (200-250 words).
Background and Significance
Briefly sketch the background leading to the present application, critically evaluate existing knowledge, and specifically identify the gaps which the project is intended to fill. State concisely the importance and health relevance of the research described in this application by relating the specific aims to the broad, long-term objectives.
Use this section to provide an account of your or your Yale faculty advisor’s preliminary studies or available data from literature pertinent to the application information that will help to establish the competence of the proposed project. (800-1000 words)
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Goals and Specific Aims
List the broad, long-term objectives of the study and what the specific research proposed in this application is intended to accomplish. State the hypothesis to be tested (for quantitative studies). (100-300 words)
Design and Methods
Describe the research design and the procedures to be used to accomplish the specific aims of the project. Include how the data will be collected, analyzed, and interpreted.
Describe any new methodology and its advantage over existing methodologies. Discuss the potential difficulties and limitations of the proposed procedures and alternative approaches to achieve the aims. If your study plan includes a questionnaire, it should be included as an Appendix. Describe how you plan to analyze your data. This section should be no longer than three single space pages, font 12, including tables and charts.
Ethics
What are the ethical issues/concerns, if any, associated with your study? (250 words)
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Please be advised that all recipients of the Downs Fellowship are required to have their proposals approved by both Yale and host-country IRB boards prior to the start of their projects. EPH, PA, and YSM and YSN students should review the information contained in the Human Investigation
Committee website: http://www.med.yale.edu/hic/index.html
. The contact person at HIC is: Jean
Larson (jean.larson@yale.edu).
Please provide a brief overview (apx. 500 words) on the political, social, and health related issues at your site and in the country as a whole that may compromise your safety and security. Please provide references (personal communication, government / nongovernmental organizations, etc.)
Please include a letter of support from 1) your Yale faculty advisor and 2) your hostcountry sponsor.
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I hereby elect voluntarily and on my own initiative to travel and conduct research as a Downs Fellow. I acknowledge that the full responsibility for any personal injury or illness, accident, risk or loss, or property damage that may be sustained by me as a result of being engaged in activities while I am a Downs Fellow, is mine. In particular,
I acknowledge that I am fully aware of the risks and hazards associated with my travel and research as a Downs Fellow, including risks relating to political unrest in connection with my travel to certain countries.
I acknowledge that the Downs Fellowship Committee, The Yale School of Public
Health, The Yale School of Medicine, The Yale School of Nursing, and Yale
University shall not be responsible for any illness, injury, accident, damage or loss suffered by me from or in connection with my participation as a Downs fellow, and hereby release and agree to hold harmless the Downs Fellowship Committee, The
Yale School of Public Health, The Yale School of Medicine, The Yale School of
Nursing, Yale University, and its officers, directors, employees, and agents from liability, illness, injury, or accident that may be sustained by me while participating as a Downs Fellow.
I further acknowledge that I have adequate health and accident insurance.
This release and hold harmless agreement is binding on myself, heirs, assigns, and personal representatives.
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Name of Participant (please print)
____________________________________________
____________________________________________
Address and Phone Number
____________________________________________
Signature
____________________________________________
Date
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