Developing Global Solutions for Global Health Problems GLOBAL HEALTH SCHOLAR EXCHANGE PROGRAMME: 2015 Application Form Room 202B, JC School of Public Health and Primary Care, Prince of Wales Hospital, Shatin. HKSAR Phone: 2252-8465 Fax: 2145-7489 Email: [email protected] Website: www.cuhkcgh.org This application form is designed for Public Health postgraduate students from overseas institutions to do a research attachment at the Chinese University of Hong Kong. 1) The closing date for 2015 Global Exchange Programme applications are as follows: Potential period exchange Application deadline Spring Term Summer Term Autumn Term January – June, 2015 June – July, 2015 September December, 2015 7 November, 2014 27 March, 2015 29 May, 2015 – (by 11.59pm, HK time) 2) Please complete ALL information in ALL sections of this application form. Incomplete forms will not be accepted by the Centre. 3) Please provide your most updated Curriculum Vitae, and photocopy of postgraduate academic reports, along with your application. 4) The completed application form and supporting documents should be submitted to the Centre for Global Office via email or fax by the applicable deadline date. 5) Any personal data provided in this form is for internal use only. Information collected will not be disclosed to any other party in a form that would identify you unless it is permitted or authorised. PERSONAL INFORMATION English Name: _________________________________ Chinese Name: ______________________ (Surname) (Given Names) Date of Birth (dd/mm/yy): ________________________ Gender: F / M Nationality (Passport): ___________________________ Hong Kong ID number: ______________( ) Correspondence Address: ___________________________________________________________ ___________________________________________________________________________________ Contact: (Home) ___________________________ (Mobile) ______________________________ Email address: _______________________________________________________________________ Current Institution: ____________________________________________________________________ Graduate Program enrolled: _____________________________________________________________ Year of Study: _____________ Cumulative GPA: _______________ Emergency Contact Name: __________________________________ Relationship: _________________________________ Tel: ____________________________________ Email: _______________________________________ LANGUAGES Spoken languages (of at least conversational level)  English  Cantonese  Mandarin  Others (Please specify): ____________________________ Reading language (of level at least needed to read a newspaper)  English  Cantonese  Mandarin  Others (Please specify): ____________________________ Written language (of level at least needed to write an informal email)  English  Cantonese  Mandarin  Others (Please specify): ____________________________ SKILLS (please tick as many as applicable and provide further information where appropriate)  Qualitative skills ______________________________________________________________________  Quantitative skills ____________________________________________________________________  Epidemiological and statistical skills______________________________________________________  Monitoring and evaluation ______________________________________________________________  Surveillance design ___________________________________________________________________  Clinical trials/lab experience ____________________________________________________________  Excellent written communication skills ____________________________________________________  Excellent interpersonal communication skills _______________________________________________  Computer/software skills; e.g. __________________________________________________________  Medical/first aid skills; e.g. _____________________________________________________________  Others (please specify): _______________________________________________________________ ______________________________________________________________________________________ AREAS OF INTEREST (Please tick as many as applicable)  Autism  Disaster preparedness  Child/ teen health  Epidemiology  Climate change  Infectious Diseases  Bioethics  Urbanisation and health  Health policy (HK & China)  Migration and health  Others (Please specify): _________________________________________________ PROPOSED DATES FOR EXCHANGE You can choose more than one:  Spring Semester (January – June 2015)  1 month  Summer Semester (June – July 2015)  2 months  Fall Semester (September – Dec 2015)  3 months Please specify your preferred Exchange time period in exact dates: _______________________________________________________________________________________ BACKGROUND (please write no more than 200 words for the following sections) 1. Tell us about yourself, your background and your interest in public health. Signature: _______________________________ Date: ___________________________ - The End 2. Which areas of public health are you most interested in? Why? 3. What relevant skills and experience do you have to contribute to innovative research projects? 4. How will this Global Exchange experience benefit your long-term goals?