UJMT Fogarty Global Health
Fellowship Program
gram
2016-2017 Application for Medical S tudents and Doctoral Scholars
Due November 1, 2015
DIRECTIONS: Applicants are required to submit a two-page research proposal, as well as supplemental
materials around their experience and planned mentorship. Candidates are expected to have spent a significant
amount of time preparing this application with the guidance of a U.S. and international mentor (U.S. based or
LMIC) affiliated with the site.
Note: Fogarty International Center has mandated that 80% of fellowship funding must go to HIV-related research
activities so, where possible, applicants in high-prevalence settings should consider how HIV might relate to their
work.
A. Email your complete application as a single PDF file to Kathryn_Salisbury@med.unc.edu
B. Your mentors/advisors will email their letters of recommendation to FGHFP@med.unc.edu
Applicant Contact Information
First Name: ________________________Middle Name: _______________________Last Name: _________________________
Email address: _________________________________
Cell phone#:______________________________
Current Address:
City:
_____________________________
State:
Zip Code:
Permanent Address:
City:
_
State:
Zip Code:
General details about proposal
Doctoral scholars are invited to apply to work at established UJMT Consortium sites in one of the nine countries listed
below.
Africa: Ghana, Malawi, South Africa, Uganda, Zambia
Asia: China, India
Latin America: Argentina, Peru
Please indicate where you would like to spend your fellowship year: _______________________________________
How did you learn about the UJMT
Fogarty Global Health Fellows Program?
Area of research interest
Proposed LMIC training site (institution
name):
Proposed mentor at LMIC training site
Letter of recommendation from mentor is
included?
Research project you intend to work on
(attach the project methodology, IRB
approval # and dates, PI biosketch,
describe your role)
Original research proposal title (attach a
2 page research proposal
Yes____
No____
Foreign Language: D o you have a working knowledge of any language other than English?
Language(s):__________________________________________ (specify: beginner, conversational, fluent)
Required Letters of Recommendation
Recommendations are to be provided separately, and emailed by the author to FGHFP@med.unc.edu
1. Prior/current research mentor: (or dean for
academic/student affairs)
Institution
Title
Email:
2. LMIC based UJMT FGHF mentor
Institution
Title
Email:
3. Will you be requesting the submission of
an additional letter of recommendation?
Yes____
No____
Name
Title
Email:
Award requested (check one)
_____Full award (includes stipend, insurance, research and travel)
_____Research and travel only
_____Other: _______________________________________________________________________
Proposed appointment dates of 11-month traineeship:______________________________________
(Note: Fellows are required to work a minimum of 36 hours per week on their research for 11 months, and
a minimum of 10 months must be spent overseas.)
Title of the T32 or other training program (current or in the last 12-24 months):
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________
Program Director:___________________________________________________________________
Email address:______________________________________________________________________
Describe prior experience in resource-poor settings, domestic or international
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Demographics
1.
U.S. Citizen
_____U.S. non-national
2. Gender:
Male
Female
Prefer not to answer
3. Ethnic Category:
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
4.
Racial Category:
Permanent resident, INS A#:___________
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
More than One Race
Prefer not to answer
INSTRUCTIONS: PLEASE READ CAREFULLY
All components should be single-spaced, with 0.5” margins, and in Arial 11 point font. The page limit for
each section are specified below
1. Research Proposal (2 pages)
It is expected that applicants review the proposed research design extensively with their primary
mentor
i. Specific Aims
ii. Research Plan (overview)
a. Significance
b. Innovation
c. Approach
iii. Timeline for proposed scope of work
iv. Human Subjects (describe the IRB process and timeline for approval)
v. References should be included in the two page limit, if possible- font can be 9pt
2. Budget and budget justification, up to $7,000 (1 page)
3. Statement of career goals (1 page)
Please state why you are interested in a mentored clinical research training experience abroad,
what you expect to gain from this program. Describe how your career goals relate to international
health. Specify the area of research you are interested in exploring
4. Plan for mentorship over the Fogarty year (1 page)
5. Current curriculum vitae (2 page limit)
6. Two to three letters of recommendation. Letters will be emailed directly to Kathryn Salisbury at
fghfp@med.unc.edu.
a. Prior/current research mentor letter: This should provide a candid assessment of the candidate’s
research experiences, research potential and likelihood of a successful academic career. This
can also come from the dean for academic and student affairs at your institution.
b. Training site mentor: Your research mentor must indicate that you have been in communication
with them, have shared your research idea and they are committed to working with you. This
can be a U.S. based or LMIC based mentor.
c. Additional letters of support are accepted from other mentors or relevant LMIC site affiliates.
7. Non-official transcripts of graduate school academic performance in courses taken to date. Do not
include your undergraduate transcripts.