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Application form

2005

FROM RESEARCH TO PRACTICE:
TRAINING IN RESEARCH
IN
REPRODUCTIVE HEALTH

Methodological Issues in Health Research

2 weeks

Reproductive Health

4 weeks

14 February 2005 – 25 March 2005

organised by

the Geneva Foundation for Medical Education and Research
(WHO Collaborating Centre in Education and Research in Human Reproduction),
the International Association of Maternal and Neonatal Health (IAMANEH)
and
the UNDP/UNFPA/WHO/World Bank Special Programme for Research in Human Reproduction,
Department of Reproductive Health and Research, Family and Community Health Cluster (WHO/RHR),

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 Reproductive Health

Yes No
PERSONAL DATA
Family name
First names

female male

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
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

I will pay all costs myself  

I would like to apply for funding

I have already found funding
...............they will pay all my costs
.............. they will pay some of my costs
...............details (who/how-much/etc.)

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 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. a 1-2 page summary of the research project/thesis that will be completed/written up as part of the exams
5. an official attestation confirming your proficiency in the English language
6. two letters of reference, preferably one form your current employer
7. if possible, please submit the following document: an introduction by your Head of Department stating your role and future involvement
    in your country's National Reproductive Health Programme

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 1 November 2004.

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

Postgraduate Course in Reproductive Health

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,