Cohort 4 International Scholars Application (2018-2019) Last Name: First Initial

Cohort 4 International Scholars Application (2018-2019) Last name: First initial:

HIV Prevention Trials Network (HPTN)

International Scholars Application

** Please Note: For an application to be considered, every field is required. **

Initial proposal drafts are due29 January 2018.

Full applications due 12February 2018

Applicant’s Name:

LastFirstMiddle/Other

Preferred First Name (if different from First Name above):

Present Address:

Street Apartment Letter/Number

City State/ProvincePostal Code

Telephone (with country code):

CellHome

E-mail Address:

Primary Secondary

Permanent Address (if different than above):

Street Apartment Letter/Number

City State/ProvincePostal Code

Demographic Information

Self-identified gender:

Date of Birth:

(MM/DD/YYYY)

Project Proposal

Please describe the research project that you wish to complete from 1May 2018 – 31 October 2019. Applicants must propose a project using completed or near-complete HPTN Study datasets. Please choose from the following list of studies:HPTN 037, HPTN 039, HPTN 043, HPTN 052, HPTN 058, HPTN 063, HPTN 061, HPTN 064, HPTN 065, HPTN 067,HPTN 068, or HPTN 073. Please be certain that your mentor was somehow involved with the study of choice.See links to each study’s web page, where a copy of the study’s protocol can be found. (Max. 750 words)

Applicants must submit their project proposal for a pre-screening of appropriateness to Erica Hamilton () at least two weeks before the application due date (by29 January 2018). If further information is needed or if the applicant has difficulty locating a mentor, the applicant may contact Ms. Hamilton .

Personal Statement/Statement of Intent

Please describe how the mentored experience would nurture your research career. (Max. 1000 words).

Letters of Support

Letters are to be provided from the letter author to Ms. Erica Hamilton(), at FHI 360 directly. I (___ do or ___ do not) waive my right to review these letters. PLEASE PUT AN “X” in front of your choice.

HPTN mentor(involved with study of choice), with Title: ______

______

Telephone (with country code): ______

E-mail:______

Representative from Home Institution, with Title: ______

______

Telephone (with country code): ______

E-mail:______

One additional professional letter of recommendation (e.g. past mentor/professor/employer), with

Title: ______

Telephone (with country code): ______

E-mail:______

Education History

Please use the NIH-disseminated Biosketch for this section. A template of the NIH Biosketch can be found on the HPTN website, on the International Scholars Program web page. Include in the NIH Biosketch your Graduate-Level Academic Institution(s) and at least one undergraduate institution (e.g., the one from which you obtained your degree).

If you are currently in school, please fill out the following section:

University: ______

School within University (e.g.: School of Public Health): ______

Year (e.g.: 2nd year PhD student): ______

Primary Advisor: ______

Advisor’s Title: ______

Scholarships, Prizes, Awards, and Memberships in Honorary and Professional Societies

Five items maximum. Do not repeat if included in your NIH Biosketch.

Employment History (starting with the most recent)

Organization:Location (City, State):Last Position:Dates:

Do not repeat if included in your NIH Biosketch.

Research Experience

Prior research experience is required to be considered for the program. Please list an institution, mentor, and one project, describing your role in it. If you have multiple prior experiences, present your most relevant research experience to the HPTN.Maximum 150 words. (You may give further detail in your personal statement.)

Research Related Publications

Please list publications on which you are an author on your NIH Biosketch. You may include posters and presentations you have given at conferences.

Statistical Resources

Please indicate whether any statistical help will be needed for your proposal. Are you planning to do the analyses on your own or will you need assistance from the HTPN SDMC (Statistical and Data Management Center) at SCHARP? The core HPTN Scholar “deliverable” is one substantial research paper based on an eligible HPTN study. However, when the opportunity arises for further scientific productivity on the Scholar’s core project (i.e., more than one paper), SCHARP will either provide the needed data for Scholar use or will provide additional SCHARP support if this is possible at the time of the work. This will be dependent upon network resources.