Pragmatic Evaluation in Physical Activity
Cape Town, 5th – 7th June 2016
APPLICATION FORM
To ensure the most appropriate participants are selected, applying to attend the Pragmatic
Evaluation in Physical Activity course is a selective process. There are four parts to the application
and the weighting of each component is clearly outlined on the attached forms. Please do not
exceed the length outlined for each part of the application form and refer to the course
description for guidance. All information you provide will remain confidential and be stored
securely by the course organisers.
APPLICATION DEADLINE: Sunday 28 February, 2016
Please send your completed application form to pragmatic.evaluation@gmail.com
All applications received will be acknowledged with a reply email. If you do not receive this
acknowledgement within two working days, please contact the course administrators again and
resubmit your application.
Applicant Information
Contact details
First Name:
Surname:
Street address:
Postcode:
Country:
Email address:
Daytime telephone number:
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PART A (40%) – Personal Statement (1 page)
Experience as a physical activity or public health practitioner / evaluator / researcher
(max 1200 characters)
Describe your knowledge and experience in relation to physical activity program delivery, epidemiology,
evaluation design, data collection, policy development and/or statistical methods. Please also include any
other information which you feel strengthens your application.
How will attending the course benefit your personal career progression?
(max 500 characters)
Describe your future aspirations and the relevant skills you hope to develop from attending this course.
How will attending the course benefit others (e.g. colleagues, community, partners, etc)?
(max 500 characters)
Describe the broader reach and potential impact of your attendance at this course.
Write a tweet for “public health and physical activity promotion” targeted at the general public
(max 140 characters)
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PART B (20%) - Physical Activity Evaluation Proposal (1 page)
Describe the evaluation of a physical activity action (e.g. policy, project, program). This could be a
real physical activity action that you are planning or a theoretical idea that you would like to
develop. You should describe an evaluation which has not yet happened (i.e. do not describe a
completed evaluation). This is an opportunity for you to demonstrate your current understanding
of physical activity actions and their pragmatic evaluation. Remember… this is an application for a
course to learn more about pragmatic evaluation - your response does not have to be perfect!
Description of the physical activity action (max 600 characters)
Describe the target population, setting and aims of the physical activity action that you propose to evaluate
Rationale for evaluating the physical activity action (max 400 characters)
Describe why it is important to complete your proposed evaluation and identify any existing evidence
Proposed methods of evaluation (max 800 characters)
Describe the potential sample, study design, outcomes and metrics for your proposed evaluation
Potential implications of evaluation findings (max 400 characters)
Indicate how future policy, practice and research may be informed by your proposed evaluation
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PART C (20%) – CV of Applicant (1 page)
Education and Qualifications (please include highest and most relevant qualifications)
Start date
End date
Institution
Qualifications
Employment History (please include your current employment and most relevant previous employment)
Start date End date
Employer
Position title and description of responsibilities
Written Report Record (e.g. peer-reviewed publication, program reports, evaluation reports, etc)
Please list your three most relevant written reports, in chronological order starting with the most recent.
1.
2.
3.
Oral Presentation Record (e.g. conferences, workplace seminars, stakeholder meetings, etc)
Please list your three most relevant oral presentations, in chronological order starting with the most recent.
1.
2.
3.
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PART D (20%) – Statement from Manager/Mentor/Supervisor (1 page)
Professional reference for applicant to attend course on Pragmatic Evaluation in Physical Activity
(max 2000 characters)
To assist the course organisers select participants that are best suited to the course structure and content,
please provide a reference for the applicant that specifically addresses the following criteria:
- Relevant previous experience and future potential;
- Demonstrated work ethic;
- Interpersonal collaborative skills;
- Open-minded approach to learning.
Signature (manager / mentor/ supervisor)
By signing this form you confirm that all information provided is accurate to the best of your knowledge.
Signature:
Date:
5
PART E – Declaration
Conference participation
Do you intend to participate in the International Society of Behavioral Nutrition and Physical
Activity (ISBNPA) Annual Meeting in Cape Town on 8-11 June, 2016?
Yes
☐
(NOTE: This information is collected for internal evaluation purposes only and will have no
influence on whether you are accepted for the course)
No
☐
Yes
☐
No
☐
Funding
Do you have funding secured to support your attendance at the course?
(NOTE: This information is collected for internal evaluation purposes only and will have no
influence on whether you are accepted for the course)
Signature (applicant)
By signing this form you confirm that all information provided is accurate to the best of your knowledge.
Signature:
Date:
Please send your completed application form to pragmatic.evaluation@gmail.com
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