2007CGHScholarApplication

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2008 Center for Global Health
University Scholar Award Application

Instructions:

Please be aware that you are responsible for adhering to all International Studies Office and Institutional Review Board requirements including ethical requirements regarding working with humans, animals and hazadous substances.

Please cut and paste text into each text field. Fields accommodate up to approximately a page of text.

Personal Information

First Name

Last Name

Street Address

City

State

Zip Code

Cell Phone

Email Address

School, Major and Year (i.e. CLAS, Economics and Psychology Double Major, 3rd Year)

Last 4 digits of SSN

Proposal Information

Descriptive Project Title

Country of Interest

Proposed Dates for project

I Background/Rationale

Describe why you are seeking this global health experience, including ties to personal goals, professional goals and your academic career at UVa.

II Project Description

Service-Learning is defined here.

Describe why your project is a service-learning project?

What do you plan to do. (i.e., How do you plan to be of use to your target population)

Host Organization name and supervisor name

Host organization purpose / mission

Your job description

Description of the target population

III Learning Objectives

Use the guidelines for writing your learning objectives.

What do you want to learn?

What are the targeted learning objectives associated with your project?

Background or rationale for your learning objective(s)

Your hypothesis or question, associated with your objective(s)

Methodology for data collection / analysis

Benefits: What benefits can reasonably be expected from your project (Benefits may be to the participants, to the knowledge base of the area.

Risks: What risks can reasonably be expected from your project? Are there any possible physical, psychological, professional or personal risks and/or hazards for the participants? (Please be sensitive regarding potential risks for participants.)

What will be done with what you've learning during your project? How will this information be shared with the people in the location where you conduct your project? Do you expect to present, publish or disseminate your findings in a public forum?

IV Additional Information

"Projects which include research on animals are limited to supporting ongoing and approved work with international collaborators of UVa faculty.

If such work is proposed, include 1) the name and contact information of the UVa faculty member who will oversee your work and 2) the date you completed appropriate IACUC Orientation training ( http://www.virginia.edu/vprgs/iacuc/training.html "

Itinerary including in-country travel, data collection, analysis and other project activities.

Estimated Budget including vaccines, health insurance, evacuation insurance, requisite visas, international airfare, meals and lodging, project supplies and the actual total cost of your project. The typical CGH award does not exceed 3K.

Describe other funding sources for your project including monies you will raise on your own. You will be required to disclose other UVA funding sources at the close of your project.

Please upload your CV

V Ethics Training

Provide documentation of completion of following CITI modules:

History and ethical principles
Defining research with human subjects
Assessing risk in social and behavioral sciences
International Research -SBR

VI Faculty Mentor Information

Please send letters of support from each faculty mentor (including your host country mentor) via email to aballard@virginia.edu or to Center for Global Health/PO Box 800822.

UVA Faculty Mentor 1 Name

UVA Department

Phone

Email Address

UVA Faculty Mentor 2 Name

UVA Department

Phone

Email Address

If you are involving additional faculty mentors, please ask them to forward their letters of support for you to aballard@virginia.edu

In Country Host Mentor Name

Host Institution

Street Address

City

Postal Code

Country

Phone

Email Address

University of Virginia Health System

2008 Center for Global Health University Scholar Award Application

I Background/Rationale

II Project Description

III Learning Objectives

IV Additional Information

V Ethics Training

2008 Center for Global Health
University Scholar Award Application