Postgraduate Training in Chronic Disease 2004

Application form

2004

FROM RESEARCH TO PRACTICE:
POSTGRADUATE TRAINING
IN
CHRONIC DISEASE

Methodological Issues in Health Research

2 weeks

Chronic Disease

4 weeks

23 February 2004 – 2 April 2004

organised by

the Geneva Foundation for Medical Education and Research ,
the WHO Noncommunicable Diseases and Mental Health Cluster (WHO/NMH)

in collaboration with

the Department of Health of the Canton of Geneva,
the Faculty of Medicine of the University of Geneva
and
the Geneva Medical Association

COURSE CHOICE
I wish to apply to participate in the Course in Methodological Issues in Health Research; and Chronic Disease Yes No
PERSONAL DATA
Family name
First names
Maiden name
Date and place of birth
Nationality
Position held at present (state your activities and responsibilities)
Previous employments (last 4)
Family status
ADDRESS, TELEPHONE, FAX, E-MAIL
Professional address
Telephone number and Fax number with country and area codes
Personal address
Telephone number and Fax number with country and area codes
E-mail address (If you don't have one, you could get one at no cost at Yahoo.com or Hotmail.com)
LANGUAGE SKILLS

Mother tongue
Other languages	Reading			Writing			Speaking
Other languages	Excellent	Good	Fair	Excellent	Good	Fair	Excellent	Good	Fair
1.
2.
3.
4.
Please note that the lectures and exams will be held in English. Therefore, it is extremely important that your level of understanding, expressing yourself and writing in English is adequate.

EDUCATION
University studies
University
Country
Faculty
Successful exams and year of graduation
Obtained university title and exact field
Academic certificates or diplomas and years when they were obtained
FINANCING
If you are accepted to the Course, please indicate, who will finance your participation in the Course	Self Others (please give details):
ACCOMMODATION
If you are accepted to the Course, please indicate, if you would like the Course organisers to reserve a student's room for you in Geneva		Yes No
ENCLOSURES
Please attach the following documents: 1. curriculum vitae, including sections on: your current and previous positions; responsibilities in research, teaching and clinical work; the institution in which you work; and a list of publications (if available) 2. a certified copy of the diploma in medicine, public health or social science and any additional diplomas 3. a letter of motivation stating clearly your interests and reasons for applying to the Course (1 A 4 page maximum) 4. an official attestation confirming your proficiency in the English language 5. two letters of reference, preferably one from your current employer 6. if possible, please submit the following document: an introduction by your Head of Department stating your role in the department and at national level

All application documents should be sent electronically (secretariat@gfmer.ch) except copies of diplomas, copy of attestation of English language proficiency and letters of reference, which should be sent by post or by fax. The deadline for receipt of applications is 05 December 2003.

Documents to be dispatched by post/fax should be sent to:

Postgraduate Course in Chronic Disease

Geneva Foundation for Medical Education and Research

3, Route de Florissant

CH-1206 Geneva

Switzerland

Fax: +0041.22.346.78.34

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Edited by Aldo Campana,