Multidisciplinary International Research Training Program
Harvard School of Public Health
Dear Applicant:
The Harvard School of Public Health-Multidisciplinary International Research Training (HSPH-MIRT) Program is a
national program designed to encourage underrepresented students to elect a career path in public-health related
biomedical and social science research. This program provides fellows with experience in population-based health
research in developing countries.
Priority will be given to undergraduates with at least a junior standing by the beginning of summer quarter 2014.
An application packet for the HSPH MIRT Program is attached. Please read it carefully. It is your responsibility to
see that your complete application is received by January 3, 2014.
The application packet consists of:
1.
2.
3.
4.
5.
6.
General Information Sheet (this page)
Student Responsibility Sheet
Application Form
Three Recommendation Forms
Checklist
Curriculum Vitae or Resume
Your completed application form, recommendation forms and a copy of your transcript are due in the HSPH MIRT
Program Office by January 3, 2014. NO APPLICATION PACKETS WILL BE PROCESSED IF ANY OF THESE
ITEMS ARE MISSING.
FIRST, fill out the application form completely, typing or printing all your answers.
SECOND, complete the essay questions, typing all your responses.
THIRD, fill in the top part of the recommendation form. Then give the form to the appropriate individual to
complete. Indicate to each reference that your application will not be evaluated without these forms. Select these
individuals carefully since they are important in the evaluation process. Instruct the evaluators to return the forms to
you in a sealed envelope with their signature across the seal.
Recommendations must come from:
A. Academic Counselor, Academic Advisor or Mentor
B. Science Professor or Research Preceptor
C. Employer or Personal Reference (non-family)
Ask him/her to fill out the form promptly, place the completed form in a sealed envelope with their signature across
the flap and return it to you to include in your application packet. Submit the recommendations with your
application.
FOURTH, contact the Registrar at your school and request that a copy of your transcripts be sent to you in a sealed
envelope. Submit the transcripts with your application. Please attach the transcripts of every college and university
you have ever attended (whether or not a degree was awarded). The transcripts you attach should be the same as those
listed under ‘Colleges and Universities Attended’ on the application form.
All qualified applicants will be interviewed after the application deadline. Final selection is based on your application
and the interview. You will be notified of your fellowship award in March.
Thank you for your cooperation. Good luck with your application!
2/12/2016
INFORMATION & RESPONSIBILITIES OF SELECTED FELLOWS
Multidisciplinary International Research Training Program
Harvard School of Public Health
1. Award Payments
As determined by NIH, you will receive your summer stipend installments. The stipend are $1,200 per
month for undergraduates, $1600 per month for Masters level degree students, and $2000 per month for
Pre-doctoral degree level fellows. MIRT Fellows will be overseas for an average of ten weeks.
2. Change of Address Notification
Be sure the program is advised of any address change. This will facilitate our communication with your
regarding program developments and your career decisions.
You may reach the MIRT Program Office from 9:00am-5:00pm, Monday-Friday
at (617) 432-1071 or e-mail our office at bgelaye@hsph.harvard.edu.
3. Lodging and Transportation Arrangements
Living accommodations will be arranged by the MIRT Program Office. Funds for lodging and
transportation will be provided by the program.
Airline tickets will be issued by the HSPH MIRT Program. All undergraduate fellows must leave and
return together unless you make special arrangements prior to departure with the MIRT Program Office.
4. Orientation
All selected MIRT fellows will be required to participate in a pre-departure orientation program at
Harvard School of Public Health. The orientation will be cover academic, administrative, health, sociopolitical and cultural information necessary for successful participation in the program. This is a
mandatory pre-travel orientation program. Fellows will receive a required reading list of handbooks and
journal articles with information about foreign travel, public health and the foreign training site.
5. Academic Credit
MIRT requires that all students complete a research paper and abstract. The program has no influence
on what your home university considers to be work that is worthy of receiving credit. If you want to
receive credit for your summer project that you do with the MIRT Program, then it will entirely be up to
you to negotiate this with your advisor or professor that you expect to receive credit from.
Interested students should contact their academic advisors or professor at their home institution first to
determine the process for receiving credit.
6. Documentation for Travel
Selected participants must obtain a passport, visa and immunizations prior to departure. The MIRT
Program Office will assist you in getting visa and provide you with more information on the necessary
documentation and required immunizations for foreign travel; however, you are responsible for making
arrangements and paying for the documents and immunizations prior to the orientation.
2/12/2016
APPLICATION FORM
Multidisciplinary International Research Training Program
Harvard School of Public Health
DUE DATE: January 3, 2014
~ Please type or print ~
Name (last)
(first)
Current Address (Street)
(City)
(middle)
(State)
Social Security #
(Zip)
(Phone)
(Work Phone)
Your E-mail Address
Emergency Contact (Name)
(Street)
(City)
(State)
(Zip)
(Phone)
Emergency Contact Email(if available)
Anticipated Standing When Program Begins in June, 2013
 Sophomore  Junior  Senior  Graduate (yr.) __________  Faculty (rank)
Degree Sought
Currently Seeking:
Highest Degree Likely to be Sought:
G.P.A.:
Please Indicate Any Foreign Language Ability
Language/s:
Fair____
Good____
Excellent____
Native____
Language/s:
Fair____
Good____
Excellent____
Native____
Graduates and Faculty Only
Are you currently on an NIH funded training grant?
yes_____ no_____
specify
Colleges and Universities Attended: Include institutions you are now attending (please submit transcripts)
College or University Name
Location
Dates (from/to)
Major
1.
2.
3.
Please submit your curriculum vitae
2/12/2016
MIRT Program APPLICATION
DEMOGRAPHIC INFORMATION
Multidisciplinary International Research Training Program
Harvard School of Public Health
Applicant Name:
______________________________________________________________________________________________________
E-mail Address
Birthdate (month, day, year)
Birthplace
Sex
Marital Status
No. of children
_
_____________________________________________________________________________________________________
U.S. citizen (if no, see next)
Are you a Permanent Resident?
yes
yes
no
Racial/Ethnic Identification:
Type of visa held
Visa Status
Reg. Number
no
 Hispanic/Latino
(please specify)
 Black/African American  Native American  Asian/Pacific Islander
 Other (please specify)
(please specify)
Are you currently receiving need-based financial support through the Financial Aid Office?
yes
no
2/12/2016
Faculty Note: Information below does not apply to Faculty applicants. Check with the MIRT Program Office for specific fellowship criteria.
Previous Work Experience: Please list three jobs you held in chronological order
Job Title
Employer
Location
Dates of Employment
1.
2.
3.
Socio-demographic Data
Which of the following best describes your parents annual household income?
___ $14,999 & under ___ $15,000 - 25,999
___ $26,000 - $35,999 ___ $36,000 - 45,999 ___ $46,000 - 55,999 ___ $56,000 - $65,999 ___ $66,000 & up
Which of the following best describes your annual household income?
$26,000 - $35,999 ___ $36,000 - $45,999 ___ $46,000 - $55,999
___ $14,999 & under
___ $56,000 & up
___ $15,000 - 25,999
___
Did your parents claim you on their 2012 IRS income tax return? ___ yes ____ no ____________________________ other
What is the occupation of your father?
Highest level of education achieved?
What is the occupation of your mother?
Highest level of education achieved?
Recommendations requested from:
A.
Name:
Title:
Institution:
Dept./School:
Name:
Title:
Institution:
Dept./School:
Name:
Title:
Institution:
Dept./School:
Phone:
B.
Phone:
C.
Phone:
Personal Statements
In no more than six typed, double-spaced pages, please answer the following questions, include a heading for each.
1. Briefly tell us
 Why you decided to apply to this program.
 The projected benefits of this experience to your course of study and long-term academic plans.
2. What values are important in your life?
 How do you see your future professional life fitting with or promoting those values?
3. Describe any past research experiences or other relevant skills not mentioned above. With whom did you work?
4. Have you ever traveled, studied or lived abroad? If yes, what was the nature of your trip?
5. What are your

Honors and Awards

Special Interests and Community/Organizational Involvement
 Work or Volunteer Experiences
I certify that this information is correct and complete.
Signature
Date
2/12/2016
RECOMMENDATION FORM
A. ACADEMIC COUNSELOR, ADVISOR OR MENTOR
Multidisciplinary International Research Training Program
Harvard School of Public Health
To be completed by applicant
Name of applicant:
Name and title of person to complete this reference:
Relation of recommender to applicant:
I give my permission for this reference to remain confidential between the Harvard School of Public Health and the
recommender.
Signature of applicant:
Date:
To be completed by the recommender
The student named above is an applicant for the Multidisciplinary International Research Training Program. MIRT is
a national program designed to encourage students to pursue careers in biomedical and behavioral research. The
program provides full support for multidisciplinary undergraduates and graduate students to do research work
overseas. Participants must be highly motivated, emotionally mature and able to adapt easily to people with different
social and cultural backgrounds. Your candid evaluation will enable us to determine the applicant’s suitability for this
program. Please indicate your assessment in the space below and make your comments on the reverse side. We
appreciate your cooperation and prompt response as the student must submit their completed application by
January 3, 2014
Please rate the applicant in comparison with other individuals of the same background and experience with
whom you have been acquainted.
Outstanding
Above
Average
Average
Below
Average
No Chance
To Observe
Motivation and initiative
Perseverance and commitment
Leadership qualities
Ability to benefit from research abroad
Ability to analyze problems
Written communication
Problem solving skills
Adaptable/Flexible
Intellectually curious
Emotionally Mature
Socially Motivated
Ability to interact effectively with
faculty, students and co-workers
PLEASE COMPLETE REVERSE SIDE OF FORM
2/12/2016
Please comment on the applicant’s academic or employment record, potential and personal qualities. We are
especially interested in any other information you might add that would not be apparent in the candidate’s
record.
* use continuation page(s) as necessary
Please indicate whether the applicant is in good standing and will continue enrollment in an academic program?
Please check the appropriate box:
 I highly recommend the applicant
 I recommend the applicant
 I recommend the applicant with reservation
 I do not recommend the applicant
____________________________________________________________________________________________
Your name and title (please type or print)
Signature
Date
____________________________________________________________________________________________
Complete mailing address
Phone
Please return the completed form to the APPLICANT in a sealed envelope with your signature across the
seal.
If you have any questions, you may contact: Dr. Bizu Gelaye
677 Huntington Avenue
Department of Epidemiology
Kresge, 501
Boston, MA 02115
Tel: 617-432-1071
bgelaye@hsph.harvard.edu
2/12/2016
RECOMMENDATION FORM
B. SCIENCE PROFESSOR OR RESEARCH PRECEPTOR
Multidisciplinary International Research Training Program
Harvard School of Public Health
To be completed by applicant
Name of applicant:
Name and title of person to complete this reference:
Relation of recommender to applicant:
-
I give my permission for this reference to remain confidential between the Harvard School of Public Health and the
recommender.
Signature of applicant:
Date:
To be completed by the recommender
The student named above is an applicant for the Multidisciplinary International Research Training Program. MIRT is
a national program designed to encourage students to pursue careers in biomedical and behavioral research. The
program provides full support for multidisciplinary undergraduates and graduate students to do research work
overseas. Participants must be highly motivated, emotionally mature and able to adapt easily to people with different
social and cultural backgrounds. Your candid evaluation will enable us to determine the applicant’s suitability for this
program. Please indicate your assessment in the space below and make your comments on the reverse side. We
appreciate your cooperation and prompt response as the student must submit their completed application by
January 3, 2014
Please rate the applicant in comparison with other individuals of the same background and experience with
whom you have been acquainted.
Outstanding
Above
Average
Average
Below
Average
No Chance
To Observe
Motivation and initiative
Perseverance and commitment
Leadership qualities
Ability to benefit from research abroad
Ability to analyze problems
Written communication
Problem solving skills
Adaptable/Flexible
Intellectually curious
Emotionally Mature
Socially Motivated
Ability to interact effectively with
faculty, students and co-workers
PLEASE COMPLETE REVERSE SIDE OF FORM
2/12/2016
Please comment on the applicant’s academic or employment record, potential and personal qualities. We are
especially interested in any other information you might add that would not be apparent in the candidate’s
record.
* use continuation page(s) as necessary
In what capacity and for how long have you known the applicant?
Please check the appropriate box:
 I highly recommend the applicant
 I recommend the applicant
 I recommend the applicant with reservation
 I do not recommend the applicant
____________________________________________________________________________________________
Your name and title (please type or print)
Signature
Date
____________________________________________________________________________________________
Complete mailing address
Phone
Please return the completed form to the APPLICANT in a sealed envelope with your signature across the
seal.
If you have any questions, you may contact: Dr. Bizu Gelaye
677 Huntington Avenue
Department of Epidemiology, Kresge 501
Boston, MA 02115
617-432-1071
bgelaye@hsph.harvard.edu
2/12/2016
RECOMMENDATION FORM
C. EMPLOYER OR PERSONAL REFERENCE
Multidisciplinary International Research Training Program
Harvard School of Public Health
To be completed by applicant
Name of applicant:
Name and title of person to complete this reference:
Relation of recommender to applicant:
I give my permission for this reference to remain confidential between the Harvard School of Public Health and the
recommender.
Signature of applicant:
Date:
To be completed by the recommender
The student named above is an applicant for the Multidisciplinary International Research Training Program. MIRT is
a national program designed to encourage students to pursue careers in biomedical and behavioral research. The
program provides full support for multidisciplinary undergraduates and graduate students to do research work
overseas. Participants must be highly motivated, emotionally mature and able to adapt easily to people with different
social and cultural backgrounds. Your candid evaluation will enable us to determine the applicant’s suitability for this
program. Please indicate your assessment in the space below and make your comments on the reverse side. We
appreciate your cooperation and prompt response as the student must submit their completed application by
January 3, 2014
Please rate the applicant in comparison with other individuals of the same background and experience with
whom you have been acquainted.
Outstanding
Above
Average
Average
Below
Average
No Chance
To Observe
Motivation and initiative
Perseverance and commitment
Leadership qualities
Ability to benefit from research abroad
Ability to analyze problems
Written communication
Problem solving skills
Adaptable/Flexible
Intellectually curious
Emotionally Mature
Socially Motivated
Ability to interact effectively with
faculty, students and co-workers
PLEASE COMPLETE REVERSE SIDE OF FORM
2/12/2016
Please comment on the applicant’s academic or employment record, potential and personal qualities. We are
especially interested in any other information you might add that would not be apparent in the candidate’s
record.
* use continuation page(s) as necessary
In what capacity and for how long have you known the applicant?
Please check the appropriate box:
 I highly recommend the applicant
 I recommend the applicant
 I recommend the applicant with reservation
 I do not recommend the applicant
____________________________________________________________________________________________
Your name and title (please type or print)
Signature
Date
____________________________________________________________________________________________
Complete mailing address
Phone
Please return the completed form to the APPLICANT in a sealed envelope with your signature across the
seal.
If you have any questions, you may contact: Dr. Bizu Gelaye
677 Huntington Avenue
Department of Epidemiology, Kresge 501
Boston, MA 02115
617-432-1071
bgelaye@hsph.harvard.edu
2/12/2016
CHECKLIST
Multidisciplinary International Research Training Program
Harvard School of Public Health
Did you...





complete the application form and this checklist form?
include your typed essays?
provide the recommendation forms to the recommender and include the completed forms with your
application? (The forms are lettered A, B, C, please list them in order on the back side of your
application form in the space provided).
include official transcripts of your grades and submit them with your application packet?
Include your curriculum vitae (resume) with your application packet
How did you hear about the MIRT Program?
Friend
MIRT Alumni
Professor
Advisor/Mentor
In the newspaper
Poster
 In a meeting/conference

Program Web Site
 From other program
 E-mail
 Other
name?
who?
who?
dept.
who?
what paper?
located where?
which one?
which one?
origin of e-mail list or list server _________________________________
please describe
DON’T FORGET!

Your completed application must be in our office by the
January 3, 2014 deadline
MAIL YOUR APPLICATION PACKET TO:
HSPH MIRT Program
677 Huntington Avenue
Department of Epidemiology,
Kresge, 501
Boston, MA 02115

2/12/2016