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									                         National Institute of Epidemiology, ICMR, Ayapakkam, Chennai 600 077
                         “Centrally Co-ordinated Bioethics Education for India” continuation of
                                   “Long Term Training Program in Bioethics in India”


                                                       Personal Information Sheet


Dear Nominee,


As you have been nominated by your institute to pursue one year online PG Diploma Program in Bioethics under
the ICMR-IGNOU joint initiative funded by NIH. Kindly fill in the form and send it back to us by post by marking on
the cover “Application for Bioethics course” or by email to priya.jeyachandran@gmail.com with the same topic as
subject.

Documents required:
Please fill this form carefully giving us as many details as possible. When sending the filled information sheet to us
you confirm that the information given on this form is correct and complete.

Please send the following additional documents by post to Dr.Nandini K Kumar, Co-Investigator of NIH Project,
                                                             nd
National Institute of Epidemiology, R-127 Second Main Road, 2 Avenue, TNHB, Ayapakkam, Chennai-600 077,
and scanned copy by email as advance copy to priya.jeyachandran@gmail.com. The education certificate should
be self-attested copy of the original.

- Your curriculum vitae (CV) as per the enclosed format
- Your secondary school's leaving certificate
- Your university certificates
- Certificate from Institute Head
- Write up on topic of your particular interest in the area of Bioethics

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What happens after you send this form to us?


A maximum of 50 students will be enrolled in the program
                                                                                                                   th
Please note: The current application period is for the year 2012. The final deadline for the applications will be 7
May 2012.

Please give us all requested information for our records to enable your selection.
                                            Personal Information Sheet - 2012
                                  One year Online PG Diploma Program in Bioethics




PERSONAL INFORMATION

Dr/ Prof /Mr/Mrs/Ms /

Name(s):

Designation                                                                                               Affix recent
                                                                                                       Passport size photo
Office Address:




Telephone (with STD code):                          Office:     Residential:          Mobile:                 Fax:



Residential Address:




Email:


Date of Birth (dd/mm/yyyy):              Gender :                               Marital Status:  Married    Unmarried




EDUCATION - Begin with graduation details.



                                                                 DEGREE
                  INSTITUTION AND LOCATION                                      YEAR(s)            FIELD OF STUDY
                                                              (if applicable)
PREREQUISITES FOR THE PROGRAM
This information will be used to evaluate your qualification for the Online PG Diploma Program in Bioethics and allow
us to judge their relevance for our Program.
1. Ethics related experience if any: Researcher/ Chairperson/ Member Secretary/ Member of Ethics Committee)




2. Please specify the workshop/ courses/ training you have attended in the area of Bioethics. Enclose as annexure if
   required.




3. Please describe clearly in your own words (not more than one page A4 size) on topic of your particular interest in
the area of Bioethics and send it as annexure.
Please note: This statement is essential for your application. Please tell us about your personal motivation and
about your expectations, as for example: Why do you want to study this programme? We will only accept
applications with a detailed and convincing statement of intent!




Add any information that might be relevant for your application.




                                        CERTIFICATE TO BE SIGNED BY TRAINEE

I certify that the information provided by me in the Personal Information form for one-year online PG Diploma program in
Bioethics, 2012 is true and correct to the best of my knowledge.

If selected, I shall follow all instructions provided by ICMR related to the program. I also understand that if I am unable to
complete the course I will have to return the fees and any other facility provided by ICMR for the program.


Signature of Trainee:__________________
(Name in Block letters with Date)

Name: _______________________




                             CERTIFICATE TO BE SIGNED BY HEAD OF THE INSTITUTION

I     certify     that    the     applicant      Mr./Ms./Dr._________________________________________________      working
as_________________________________ will be provided opportunities to promote activities in the area of Bioethics within the
institution/ region and shall facilitate organization of program in bioethics.




Signature of Head of Institution with Date
(Name in Block letters with seal)

Name :_______________________

								
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