PfizerScholarAward

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Personal Information
______________________________________________

Name

Phone

Email Address

School and Major

Current Year (i.e. 1st year SMD student)

Last 4 digits of SSN

UVa Mentor Information
______________________________________________

UVa Mentor 1 Name

UVA Mentor 1 Department

UVA mentor 1 Email Address

UVa Mentor 2 Name

UVA Mentor2 Department

UVa Mentor 2 Email Address

In-Country Host Mentor Information
______________________________________________

In-Country Host Name

Host Institution or University

Street Address

City or Province

Postal Code

In-Country Host Email Address

Project Information
______________________________________________

Descriptive Project Title

Country of Interest

Project Narrative to include the following:

Background
Rationale
Hypothysis
Methodology
Expected Outcomes
References

No more than 4 single spaced pages.

In the field provided, please upload your project narrative

In the field provided, please upload a copy of your CV.

In the field provided, please upload a budget outline including travel costs, preliminary visa, medical and insurance costs, and living expenses.

In the field provided, please upload a copy of the acceptance email or letter from your host country mentor.

Please upload a letter of recommendation from your UVA mentor.

Please upload a letter of recommendation from a second mentor.

IMPORTANT INFORMATION
______________________________________________

All UVA students conducting study, work or research abroad are required to comply with UVA/ISO policy. Funds will not be issued until all requirements are completed.

You will be required to

complete all International Studies Office Waivers
obtain health insurance abroad and medical evacuation insurance
obtain all required vaccines at UVa Student Health

In addition, if your research involves human subjects, you must apply for either HIC (Human Investigation Committee) or IRB (Internal Review Board) approval.
Upon return ... you are required to submit a final report on your work.

Please note that UVA students traveling abroad cannot travel to countries with state department travel warnings and receive any UVA support (monetary and otherwise) or academic credit.

Additional Comments

University of Virginia Health System

Personal Information ______________________________________________

UVa Mentor Information ______________________________________________

In-Country Host Mentor Information ______________________________________________

Project Information ______________________________________________

Project Narrative to include the following:

Background

Rationale

Hypothysis

Methodology

Expected Outcomes

References No more than 4 single spaced pages.

IMPORTANT INFORMATION ______________________________________________

Personal Information
______________________________________________

UVa Mentor Information
______________________________________________

In-Country Host Mentor Information
______________________________________________

Project Information
______________________________________________

References

No more than 4 single spaced pages.

IMPORTANT INFORMATION
______________________________________________