PERSONAL DATA (for AIHS use only)
ALBERTA INNOVATES – HEALTH SOLUTIONS
CLINICIAN FELLOWSHIP APPLICATION FORM
1500, 10104 – 103 Avenue, EDMONTON, AB T5J 4A7
Phone: (780) 423-5727 E-mail: grants.health@aihealthsolutions.ca
DEADLINE DATE FOR RECEIPT OF ALL CLINICIAN FELLOWSHIP APPLICATIONS IS FRIDAY, APRIL 1, 2016 at 4:00 p.m.
APPLICATIONS WILL BE ACCEPTED IF SENT BY OVERNIGHT COURIER ON THE DEADLINE DAY.
As a public body, the Alberta Innovates – Health Solutions (AIHS) is regulated by the Freedom of Information and Protection of
Privacy Act (FOIPP) of Alberta. As such, the information on this Personal Data section will be for AIHS internal use ONLY and will not
be communicated to anyone outside of AIHS.
SECTION 1: PERSONAL DATA
Name: Surname, First Name, Middle Initial(s)
Birthdate:
Year
Gender: (Check)
Month
Day
Male
Female
Permanent Mailing Address:
Phone:
E-mail:
AIHS supports Alberta research institutions in their efforts to promote and ensure the highest standards of research and scholarship practice
and behaviour. By his/her signature below, each applicant asserts that this application adheres to all research policies and procedures in place
at his/her sponsoring institution, including those regarding integrity in research and scholarship. AIHS reserves the right to confirm this
assertion through independent means. AIHS wishes to alert applicants to the consequences of misrepresentation in this application, including
misrepresentations of authorship, credentials or research support. In the event of material deviations of the information in this application from
reference sources, including citation sources (in the case of authorship), issuing organization(s) (in the case of credentials), or granting
agencies (in the case of research support), AIHS reserves the right to disqualify the applicant from the competition in question. Further AIHS
actions may include disqualifying the applicant from future AIHS competitions for a time period to be set at AIHS’s sole discretion, withdrawal of
any remaining installments of support for any existing AIHS grant or award for which misrepresentation appears in the submission, and seeking
partial or full repayment of any past financial support under any AIHS grant or award for which misrepresentation appears in the submission.
Further information on AIHS’s support for research and scholarship integrity is found in the Program Guide for the Clinician Fellowship at
http://www.aihealthsolutions.ca/funding/training-and-early-career-funding/clinician-researcher-training/clinician-fellowship/.
SECTION 2: SIGNATURES The undersigned agree to, and accept, the general conditions governing any award made pursuant to the
sponsorship of this application, as set out in the AIHS Guidelines, located at www.aihealthsolutions.ca. This application may be executed in one
or more counterparts, all of which when taken together shall constitute a fully executed version of this application. This application or a
counterpart thereof may be executed and delivered by facsimile or electronic transmission and the facsimile or electronic transmission of a
signature to another Party or Parties (or to their respective solicitors) shall be of the same force and effect as the delivery of an original
signature.
Printed Name
Candidate:
Signature
Faculty/Dept.
Primary Research Supervisor:
Co-Supervisor (if applicable):
Co-Mentor:
Career Advisor:
Supervisor’s Primary Dept.
Head/Chair:
Supervisor’s Faculty Dean:
Research Services Office:
Personal Info - 1
Clinician Fellowship 201604
Date
ALBERTA INNOVATES – HEALTH SOLUTIONS
CLINICIAN FELLOWSHIP APPLICATION FORM
1.
APPLICANT
A.
APPLICANT
Surname, First Name & Middle Initial(s)
B.
PRIMARY SUPERVISOR
Surname, First Name & Middle Initial(s)
C.
PROJECT TITLE
D.
PROGRAM
1. Indicate what university you will be completing your training at:
2. Date completed medical or professional health degree: xxxx/xx/xx
YYYY/MM/DD
3. Do you have a license and/or practice permit to practice as a healthcare professional in Alberta?
YES
NO
If no, date of expected license and/or practice permit: xxxx/xx/xx
YYYY/MM/DD
4. Is the proposed Research Project considered cancer research?
YES
NO
5. Does the proposed Research Project align with ACPLF priority areas/cancer prevention*?
please fill out Section E.
YES
NO – If Yes,
*Please refer to the AIHS website for cancer prevention definition and ACPLF priority areas. Eligible students will receive an additional
$500/year incentive to their research allowance.
Application - 1
Clinician Fellowship 201604
APPLICANT NAME
E.
CANCER RELATED RESEARCH (if applicable)
Please describe the significance of your Research Project and how it relates to cancer prevention and screening.
Describe how the proposed research complements ACPLF priority areas currently in place.
F.
ACADEMIC BACKGROUND OF APPLICANT
Please list all current and completed post-secondary programs.
Degree
G.
University/Institution
Country
Supervisor
Dates of Enrollment
TO
(YYYY/MM)
FROM
(YYYY/MM)
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
ACADEMIC INTERRUPTION
Include relevant academic interruptions in your career progress, please provide an explanation indicating the period and
reasons for the interruption (i.e. Parental Leave, Bereavement Leave, Sabbatical, Work Experience). Describe how these
interruptions have affected your career plan.
Application - 2
Clinician Fellowship 201604
APPLICANT NAME
H.
RESEARCH AND OTHER RELEVANT WORK EXPERIENCE OF APPLICANT
FROM:
(YYYY/MM)
TO:
(YYYY/MM)
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
xxxx/xx
I.
Position
Institution/Company/City/Country
Supervisor's Name
UNIVERSITY ACADEMIC ACHIEVEMENTS (Prizes, Honors, Awards) (Use additional pages if necessary)
Prizes/Honors/Awards
Application - 3
Awarded By
Clinician Fellowship 201604
Local/Provincial/
National/International
Year Won/Held
APPLICANT NAME
J.
APPLICANT’S ACCOMPLISHMENTS
Outline any relevant academic, leadership, work and/or research accomplishments and/or experiences that have
contributed to your career development to date. Contributions described in this section may include academic, nonacademic and research achievements. Provide background information on major scholarships or awards and their
significance. Do not exceed space below. Publications are to be listed on a separate page, please see application
instructions as failure to comply with the instructions may cause a proposal to be deemed ineligible.
Publication list attached?
Application - 4
YES
NO
Clinician Fellowship 201604
APPLICANT NAME
K.
APPLICANT’S CAREER DEVELOPMENT PLAN
Describe your career goal(s) and how the above listed achievements, publications, awards and related work and research
experiences has prepared you to this point to meet your career aspirations. Also, outline the reasons for undertaking the
current program of study as it relates to your career progression, your specific career objectives and how your future
career plan(s) will be enhanced by the proposed research training experience outlined in this application. Clearly describe
and justify the rationale behind the selection of the mentorship advisors and how the members relate to your career
development plan. Do not exceed space below.
Application - 5
Clinician Fellowship 201604
APPLICANT NAME
2.
LETTERS OF REFERENCE
Identify the three individuals who have been asked to submit a letter of reference on your behalf. The primary
research supervisor may be one of the three.
Name
Institution/Organization
Email Address
Letters of reference should highlight the applicant’s strengths as they relate to the suitability and experience for the
proposed work in this training environment (e.g. originality, technical ability, demonstrated skills, judgment, critical skills,
etc.) and the benefit that the proposed experience would provide the applicant towards their career goals.
Append the three confidential letters of reference (in signed sealed envelopes) to the application package.
Application - 6
Clinician Fellowship 201604
APPLICANT NAME
3.
TRAINING ENVIRONMENT
A.
MENTORSHIP ADVISORS
Primary Research Supervisor (Surname, First Name & Initial(s))
Complete Mailing Address – (Include Primary Dept/Faculty &
Postal Code)
Contact Information:
Phone:
xxx-xxx-xxxx
E-mail:
Co-Supervisor (If Applicable) (Surname, First Name & Initial(s))
Complete Mailing Address – (Include Primary Dept/Faculty &
Postal Code)
Contact Information:
Phone:
xxx-xxx-xxxx
E-mail:
Co-Mentor (Surname, First Name & Initial(s))
Complete Mailing Address – (Include Primary Dept/Faculty &
Postal Code)
Contact Information:
Phone:
xxx-xxx-xxxx
E-mail:
Career Advisor (Surname, First Name & Initial(s))
Complete Mailing Address – (Include Primary Dept/Faculty &
Postal Code)
Contact Information:
Phone:
E-mail:
Application - 7
Clinician Fellowship 201604
xxx-xxx-xxxx
APPLICANT NAME
B.
BIOGRAPHICAL SKETCH INFORMATION FORM
Provide the following information for each Mentorship Advisor listed in Section 3 – Training Environment, including the
primary research supervisor and co-supervisor (if applicable), co-mentor and career advisor. A maximum of four pages
(excluding this information cover page) may be submitted for each. NOTE: Only the first four pages, along with this
information cover page, will be included for each biographical sketch.
NAME and MENTORSHIP ROLE (Primary Research Supervisor,
Co-Supervisor, Co-Mentor, Career Advisor)
INSTITUTION/ORGANIZATION AND
POSITION TITLE
COMPLETE MAILING ADDRESS
EDUCATION / TRAINING / RELEVANT WORK EXPERIENCE (List only work experience relevant to the proposed
research activities)
Institution and Location
Degree
(if applicable)
Year
Field of Study
Primary Research Supervisor and Co-Supervisor (if applicable): please provide additional information according to
all headings, A through E.
Co-Mentor and Career Advisor: please provide additional information according to headings A, D and E. Headings B
and C may also be included, as appropriate.
A maximum of four pages (excluding this information cover page) may be submitted for each.
A. Peer-Reviewed Publications (not required for non-academic sectors). List published or accepted publications
only. DO NOT list those that are in preparation or submitted. List only the most recent and/or relevant publications
(last 5 years). Please indicate (i.e. underline, bold, or asterisk) any authors that were/are your trainees.
B. Other Outputs Relative to the Training Environment Activities. This may include government reports, clinical
practice guidelines, patents, knowledge exchange activities, etc.
C. List all currently active and/or pending operating research grants only. DO NOT list equipment-related or
research allowances associated with studentship or fellowship awards. Please specify if you are the principal or
co-investigator, and identify only the portion of the funding you receive.
D. Current trainees and/or staff, and indicate level of training and expected completion dates. For nonacademic sectors, please list current staff that you manage and give a short description of their roles.
E. Relevant honours, awards, recognitions related to research, mentoring and/or teaching.
Application - 8
Clinician Fellowship 201604
APPLICANT NAME
4.
RESEARCH TRAINING ENVIRONMENT
Primary Research Supervisor to Discuss the Training Environment and the Role of Trainee in the Proposed
Research Project. Describe in specific detail the resources available to support the applicant’s research and the broad
training opportunities the environment provides. Outline the benefit for the applicant training in this environment,
highlighting the facilities, and other personnel the trainee will have the opportunity to interact with. Detail the role of the
trainee in the proposed research project and how it links to the supervisor’s research program and/or research group. Do
not exceed space below.
Application - 9
Clinician Fellowship 201604
APPLICANT NAME
5.
MENTORING PLAN
The Primary Research Supervisor and Co-Mentor TO DISCUSS MENTORING ENVIRONMENT.
Describe in detail how the proposed mentorship advisors will benefit the research training, and career and professional
development of the applicant. Provide information regarding the specific plans for the interactions of the mentorship
advisors and the trainee. Please include how the Mentoring Plan will address the activities, knowledge, skills and abilities
required by the applicant to achieve the goals set out in the Career Development Plan. Do not exceed space below.
Application - 10
Clinician Fellowship 201604
APPLICANT NAME
PROJECT TITLE
6.
SIGNIFICANCE AND RELEVANCE SUMMARY
Provide a summary of the proposed research activities in non-scientific, everyday language that would be accessible to
a general audience and clearly communicates the significance and relevance of the proposed research activities. Use
analogies, simplifications, and generalizations rather than scientific and technical terms. Do not exceed the space
below. Please Note: This section may be provided to a diverse set of stakeholders, including the public.
Application - 11
Clinician Fellowship 201604
APPLICANT NAME
7.
PROPOSED RESEARCH PROJECT
The applicant is to provide a detailed description of the proposed research project for the period during which the award is
to be held. Background information should indicate the position and significance of the proposed research within the
context of the current knowledge of the field. The research plan outlining the proposed project should state the specific
objectives; outline the methodological approach; and the defined key milestones or deliverables to be achieved. Do not
exceed space below. Only references related to the project description are to be listed on a separate page.
Application - 12
Clinician Fellowship 201604
APPLICANT NAME
TRAINING OUTSIDE OF ALBERTA
To be completed only if the application is for training outside of Alberta
Note: Both the candidate and the sponsor are urged to read the Clinician Research Training Stream Program Guide
before completing this section. Do not exceed space below.
Candidate: Outline briefly your reasons for selecting the location identified herein for further training. Provide a brief
statement regarding your long-term interest in returning to Alberta.
Dean or Department Chair/Head of Sponsoring Alberta University: Provide a recommendation in the space provided
here. In particular, describe the specific interest the sponsoring university may have for the future recruitment of the
candidate back to Alberta.
Name and Title of Sponsor: ____________________________________ Signature: _______________________ Date: ____________________
Application - 13
Clinician Fellowship 201604