FIC mHealth Research Training Institute
APPLICATION FORM
APPLICANT CONTACT INFORMATION
Last Name
(surname)
First Name
(Given)
Middle
(Patronymic)
Position/Title
Institution Name
Country Based
Complete Mailing
Address
(building #, street, city,
postal code)
Institution type
University/Academic
Research Institution
For-profit
Non-profit/non-governmental
Alternative Email (optional)
E-mail
Telephone #
Country Citizenship
status
(check all that apply):
Gender
Government
Male
Other__________
Female
Citizen of (country): _______________________
Permanent Resident of (country): _______________________
Non-Resident/Citizen with legal visa status of (country): _________
APPLICANT PROFESSIONAL INFORMATION
Degree(s) Earned (list all)
Field of Degree
Year Awarded
1
2
3
4
5
Years of Research Experience
Behavioral and social sciences
Medical and health science specialties
Areas of expertise
(check all that apply)
Public health
Biological, physical or earth sciences
Computational sciences and mathematics
Engineering
Demonstration of Research experience (e.g. peer reviewed publications, research grants, research trainings. List
items and where appropriate, years).
FIC mHealth Research Training Institute Application Form
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Instructions: In the spaces below, please provide thorough but brief responses to each component of the
application narrative. Your narrative responses may not exceed the length indicated for each section and must be
completely contained inside the text boxes. All answers must be typed, in English, single-spaced and no less
than Arial 10pt font.
APPLICANT BACKGROUND: Provide a brief summary of your professional background. Be sure to include the
expertise you bring that is relevant to realizing the full potential of mHealth research.
(No more than one-half page.)
RESEARCH INTERESTS: Describe a succinct, testable research question that you are interested in addressing
with mHealth methodologies. Examples include: How could mobile technologies be harnessed to collect data
and manage noncommunicable disease (NCD) co-morbidities in people living with HIV? Can a light-weight,
disposable, and antibody-free screening device based on the principles of magnetic levitation effectively
diagnosis malaria? Can a mobile, training platform effectively provide continuing medical education to
community health workers? Review additional examples of Fogarty mHealth grant awards. This document may
inform the selection of team projects, and is intended to solicit your perspectives on the potential of mobile
technologies to address critical public health challenges, and approaches to building the evidence base that will
inform how best to harness these technologies. (No more than 1 page.)
FIC mHealth Research Training Institute Application Form
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TEAM SECTION: The mHealth Institute environment is especially suited to individuals who are willing to step
outside their particular area of interest or expertise, enjoy creative activity, can think innovatively, and can settle
in easily in the company of strangers. Please describe an experience you have had in a comparable
environment, especially one in which you worked in a multidisciplinary team. Additionally, what would you
personally and professionally gain from participating in this program? (No more than 1 page.)
The following materials should be prepared and submitted along with this application, each as a separate
document.

APPLICANT’S CURRICULUM VITAE: Use the NIH biographical sketch format. (No more than 4 pages.)

SUPPORT LETTERS: (the following materials should be compiled into ONE document)

Institutional Letter of Support: Signed letter of support from your Dean, department chair or employer.
This letter should include a description of your strengths and research potential, and the type and
duration (start and end dates) of your employment. It should also include confirmation that, if you are
invited to attend the training, you will be released from regular duties during the training period (June 6- 9,
2016, plus travel), and what concrete resources will be made available that will enable you to leverage
your experience for success. The letter of support must describe resources that your home institution will
make available to you upon returning from the training course, such as financial assistance, research
assistants, infrastructure, protected time, additional training, etc.

Two Letters of Reference: At least two signed letters of reference on institutional letterhead from
colleagues who know you well, addressing your suitability for a mobile health training that involves
multidisciplinary team work. Letters from third parties (such as companies or foundations who will support
you after the training through additional resources) are encouraged, but not required.
FIC mHealth Research Training Institute Application Form
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