INSTITUTE FOR THE STUDY OF OCCUPATION AND HEALTH
4720 Montgomery Lane ● PO Box 31220 ● Bethesda, Maryland 20824-1220

Dissertation Research Grant Program

Part 1 - BIOGRAPHICAL SKETCH (10 points total)

Please attach to your sketch the following three materials:
Ø  a document that explains the grading system of your doctoral program;
Ø  a statement indicating the criteria required for admission to your graduate program; and
Ø  a university, college, or departmental brochure that describes your required course of study.

PERSONAL DETAILS

Name (Last, First, Middle):

Address:

Tel: / Fax:

Email:

AOTA Membership Number:

Dissertation Title:

Are you a United States citizen? ______If your response is no, please give evidence that you have been lawfully admitted to the United States, and please attach copy of visa or permit to your application..

PROFESSIONAL DETAILS

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)
INSTITUTION AND LOCATION / DEGREE
(if applicable) / YEAR(s) / FIELD OF STUDY
Current Doctoral Affiliation:
Name of Department/Program/Division:
Address of Department/Program/Division:
Dates of your enrollment: from (month/year) to (month/year)
Current grade-point average:
Date expected to complete doctoral study (month/year)
Major area of study:
Type of degree expected upon completion of study:
ScD PhD EdD other (please specify)

INSTITUTE FOR THE STUDY OF OCCUPATION AND HEALTH

4720 Montgomery Lane ● PO Box 31220 ● Bethesda, Maryland 20824-1220

Dissertation Research Grant Program

BIOGRAPHICAL SKETCH (continued)

A.  Occupational Therapy Experience, Positions and Honors. List in chronological order – using no more than one page – your experiences in the field of occupational therapy as well as your experiences in research and in academe, concluding with your present position. Also list any relevant honors. (2 points total)

B.  1. List of publications. List on no more than one page your publications in chronological order; include those published, submitted, or in preparation during the past three years. (2 points total)
2. Selected publications. From your list of publications (B.1. above) choose no more than five to include with this application after this biographical sketch. Indicate in your list – with an asterisk (*) – which ones you are including. You may submit any publications you choose, abstracts of funded grant proposals, reviews of professional literature, research papers completed in your graduate program, and/or reprints of publications. For publicly available citations, URLs or PMC submission identification numbers may accompany the full reference. (2 points total)

C. Research Experience. List in chronological order – using no more than one page – your research experience, no matter what your participation/role in the research project(s) (eg. data entry, collection, or analysis, research assistant/associate, PI, consultant, etc.) Please include both federally- and non-federally-supported projects, begin with the projects that are most relevant to the research proposed in this application, and briefly indicate your role and the goal(s) of the projects. (4 points total)

APPLICANT CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge, and I accept the obligation to comply with any AOTF terms and conditions if a grant is awarded as a result of this application. I am aware that any false statements or claims may make me ineligible to receive any AOTF grants or scholarships.

Your name (printed) Date

______

Your signature

Part 1 - Bio Sketch and Supporting Information 6-10.doc Page 2 of 2