Graduate studentship application mac by 15kX36D

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									PERSONAL DATA (for AIHS use only)
                                                ALBERTA INNOVATES – HEALTH SOLUTIONS
                                               GRADUATE STUDENTSHIP APPLICATION FORM
                                              1500, 10104 – 103 Avenue, EDMONTON, AB T5J 4A7
                               Phone: (780) 423-5727 Fax: (780) 429-3509 e-mail: grants.health@albertainnovates.ca

DEADLINE DATE FOR RECEIPT OF ALL GRADUATE STUDENTSHIP APPLICATIONS IS MONDAY, OCTOBER 1, 2012 at
4:00 p.m. APPLICATIONS WILL BE ACCEPTED IF SENT BY OVERNIGHT COURIER ON THE DEADLINE DAY.
As a public body, the Alberta Innovates – Health Solutions (AIHS) is regulated by the Freedom of Information and Protection of
Privacy Act (FOIPP) of Alberta. As such, the information on this Personal Data section will be for AIHS internal use ONLY and will not
be communicated to anyone outside of AIHS.
SECTION 1: PERSONAL DATA
Name: Surname, First Name, Middle Initial(s)

Birthdate:                                                             Gender: (Check)
Year                Month          Day
                                                                       Male                    Female
Permanent Mailing Address:
                                                                       Phone:

                                                                       Fax:

                                                                       E-mail:
Alberta Innovates – Health Solutions (AIHS) supports Alberta research institutions in their efforts to promote and ensure the highest
standards of research and scholarship practice and behaviour. By his/her signature below, each applicant asserts that this application
adheres to all research policies and procedures in place at his/her sponsoring institution, including those regarding integrity in research
and scholarship. AIHS reserves the right to confirm this assertion through independent means. AIHS wishes to alert applicants to the
consequences of misrepresentation in this application, including misrepresentations of authorship, credentials or research support. In
the event of material deviations of the information in this application from reference sources, including citation sources (in the case of
authorship), issuing organization(s) (in the case of credentials), or granting agencies (in the case of research support), AIHS reserves
the right to disqualify the applicant from the competition in question. Further AIHS actions may include disqualifying the applicant from
future AIHS competitions for a time period to be set at AIHS’s sole discretion, withdrawal of any remaining installments of support for
any existing AIHS grant or award for which misrepresentation appears in the submission, and seeking partial or full repayment of any
past financial support under any AIHS grant or award for which misrepresentation appears in the submission.
Further information on AIHS’s support for research and scholarship integrity is found in the Program Guide for the Graduate
Studentship at http://www.aihealthsolutions.ca/grants/training-and-early-career-development-programs/docs/trainee-award-program-
guide.pdf.

SECTION 2: SIGNATURES The undersigned agree to, and accept, the general conditions governing any award made pursuant to
the sponsorship of this application, as set out in the AIHS Guidelines, located at www.aihealthsolutions.ca.

Printed Name                                  Signature                 Faculty/Dept.                                 Date
Candidate:

Primary Research Supervisor:

Co-Supervisor (if applicable):

Co-Mentor:

Career Advisor:

Primary Dept. Head/Chair (Applicant’s
Degree Program):

Faculty Dean (Applicant’s Degree
Program):

Research Services Office:



Personal Info - 1                                       Graduate Studentship 201210
                                   ALBERTA INNOVATES – HEALTH SOLUTIONS
                                  GRADUATE STUDENTSHIP APPLICATION FORM

1.        APPLICANT
A.    APPLICANT
Surname, First Name & Middle Initial(s)



B.    PRIMARY SUPERVISOR
Surname, First Name & Middle Initial(s)



C.        PROJECT TITLE




D.        GRADUATE PROGRAM

1. Indicate what Alberta university you are registered at:


2. Indicate the graduate program you are currently registered in:

          MSc     Start Date: xxxx/xx/xx Expected Completion Date (if applicable): xxxx/xx/xx
                            YYYY/MM/DD                                            YYYY/MM/DD

     Do you plan to transfer to PhD?        YES        NO     If YES, Expected Transfer Date: xxxx/xx/xx
                                                                                             YYYY/MM/DD

          PhD Start Date: xxxx/xx/xx            Expected Completion Date: xxxx/xx/xx
                        YYYY/MM/DD                                       YYYY/MM/DD

3. Department/Faculty registered in:


4. Year 1 of graduate program completed on xxxx/xx/xx
                                          YYYY/MM/DD

5. Do you intend to apply for the PLUS opportunity?            YES        NO


6. *Is the proposed Research Project considered cancer research?               YES    NO
*Please note this information is used for administrative purposes only.




Application - 1                          Graduate Studentship 201210
E.        CANCER RELATED RESEARCH (if applicable)                                            APPLICANT NAME
If the proposed Research Project is considered cancer research, please describe the significance of your research and
how it relates to the field of cancer. (Information provided here is used for administrative purposes only)




F.        ACADEMIC BACKGROUND OF APPLICANT

APPLICANT’S CURRENT AND COMPLETED POST-SECONDARY PROGRAMS Append all university level transcripts.

                                                                                               Dates of Enrollment
      Degree        University/Institution          Country             Supervisor         FROM               TO
                                                                                           (YYYY/MM)      (YYYY/MM)

                                                                                           xxxx/xx         xxxx/xx

                                                                                           xxxx/xx         xxxx/xx

                                                                                           xxxx/xx         xxxx/xx

                                                                                           xxxx/xx         xxxx/xx

                                                                                           xxxx/xx         xxxx/xx



G.       ACADEMIC INTERRUPTION
Include relevant academic interruptions in your career progress, please provide an explanation indicating the period and
reasons for the interruption (i.e. Parental Leave, Bereavement Leave, Sabbatical, Work Experience). Describe how these
interruptions have affected your career plan.




Application - 2                     Graduate Studentship 201210
                                                                                       APPLICANT NAME

H.        RESEARCH AND OTHER RELEVANT WORK EXPERIENCE OF APPLICANT

  FROM:              TO:
                                    Position              Institution/Company/City/Country       Supervisor's Name
(YYYY/MM)         (YYYY/MM)

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx

     xxxx/xx       xxxx/xx



I.        UNIVERSITY ACADEMIC ACHIEVEMENTS (Prizes, Honors, Awards) (Use additional pages if necessary)

                                                                           Local/Provincial/
       Prizes/Honors/Awards                    Awarded By                National/Internationa     Year Won/Held
                                                                                    l




Application - 3                   Graduate Studentship 201210
J.        APPLICANT’S ACCOMPLISHMENTS                                                              APPLICANT NAME

Outline any relevant academic, leadership, work and/or research accomplishments and/or experiences that you have
accomplished to date. Contributions described in this section may include academic, non-academic and research achievements
(please see instructions). Provide background information on major scholarships or awards and their significance. Publications
are to be listed on a separate page (please see instructions). Do not exceed space below.




Application - 4                       Graduate Studentship 201210
K.        APPLICANT’S CAREER DEVELOPMENT PLAN                                                        APPLICANT NAME

Describe your career goal(s) and how the above listed achievements, publications, awards and related work and research
experiences has prepared you to this point to meet your career aspirations. Also, outline the reasons for undertaking the current
program of study as it relates to your career progression, your specific career objectives and how your future career plan(s) will
be enhanced by the proposed research training experience outlined in this application? Clearly describe and justify the rationale
behind the selection of the mentorship advisors and how the members relate to your career development plan. Do not exceed
space below.




Application - 5                        Graduate Studentship 201210
                                                                                                      APPLICANT NAME

2.        LETTERS OF REFERENCE
Identify the three individuals who have been asked to submit a letter of reference on your behalf. The primary
research supervisor may be one of the three.

                  Name                             Institution/Organization                          Email Address




Letters of reference should highlight the applicant’s strengths as they relate to the suitability and experience for the
proposed work in this training environment (e.g. originality, technical ability, demonstrated skills, judgment, critical skills,
etc.) and the benefit that the proposed experience would provide the applicant towards their career goals.

Append the three confidential letters of reference (in signed sealed envelopes) to the application package.




Application - 6                        Graduate Studentship 201210
                                                                                         APPLICANT NAME
3.        TRAINING ENVIRONMENT
A.        MENTORSHIP ADVISORS

Primary Research Supervisor (Surname, First Name & Initial(s))


Complete Mailing Address – (Include Primary Dept/Faculty &
                                                                Contact Numbers:
Postal Code)

                                                                Phone:    xxx-xxx-xxxx

                                                                Fax:      xxx-xxx-xxxx

                                                                E-mail:
Co-Supervisor (If Applicable) (Surname, First Name & Initial(s))


Complete Mailing Address – (Include Primary Dept/Faculty &
                                                                Contact Numbers:
Postal Code)

                                                                Phone:    xxx-xxx-xxxx

                                                                Fax:      xxx-xxx-xxxx

                                                                E-mail:

Co-Mentor (Surname, First Name & Initial(s))


Complete Mailing Address – (Include Primary Dept/Faculty &
                                                                Contact Numbers:
Postal Code)

                                                                Phone:    xxx-xxx-xxxx

                                                                Fax:      xxx-xxx-xxxx

                                                                E-mail:

Career Advisor (Surname, First Name & Initial(s))



Complete Mailing Address – (Include Primary Dept/Faculty &
                                                                Contact Numbers:
Postal Code)

                                                                Phone:    xxx-xxx-xxxx

                                                                Fax:      xxx-xxx-xxxx

                                                                E-mail:




Application - 7                   Graduate Studentship 201210
                                                                                                 APPLICANT NAME
B.        Mentorship Advisors – Biographical Sketches

Provide the following information for each Mentorship Advisor, including the primary research supervisor and
co-supervisor (if applicable), co-mentor and career advisor. List the primary research supervisor and co-
supervisor first followed by the co-mentor and career advisor. A maximum of four pages (excluding this
information cover page) may be used for each mentorship advisor.

NAME and MENTORSHIP ROLE (primary research                                INSTITUTION/ORGANIZATION AND
supervisor, co-supervisor, co-mentor, career advisor)                     POSITION TITLE




EDUCATION / TRAINING / RELEVANT WORK EXPERIENCE (List only academic training and/or work
experience relevant to the current application)
                                                     Degree
                                                (if applicable)
     Institution/Company/City/Country                           Year   Field of Study
                                                     and/or
                                                    Position




The attached biographical sketch information may not exceed a total of four pages for each mentorship advisor
(excluding this information cover page). Please Note: Only the first four pages, along with this information
cover page, will be included for each biographical sketch.

The following additional information is to be provided according to the following headings:

     A. Peer Reviewed Publications. List published or accepted publications only. Do not list those that are in
        preparation or submitted. List only the most recent or relevant publications (last 5 years). Underline any authors
        that were/are your trainees.

     B. Other Outputs Relative to the Training Environment Activities. This may include government reports, clinical
        practice guidelines, patents, knowledge exchange activities, etc.

     C. List all currently active and/or pending operating research grants only. Do not list equipment-related or
        research allowances associated with studentship or fellowship awards. Please specify if you are the principal or
        co-investigator, and identify only the portion of the funding you receive.

     D. Current trainees and indicate level of training and expected completion dates. For non-academic sectors,
        please list current staff that you manage and give a short description of their roles.

     E. Relevant honours, awards, recognitions related to research, mentoring and/or teaching.



Application - 8                       Graduate Studentship 201210
                                                                                                          APPLICANT NAME
4.        RESEARCH TRAINING ENVIRONMENT
Primary Research Supervisor to Discuss the Training Environment and the Role of Trainee in the Proposed Research
Project . Describe in specific detail the resources available to support the applicant’s research and the broad training
opportunities the environment provides. Outline the benefit for the applicant training in this environment, highlighting the
facilities, and other personnel the trainee will have the opportunity to interact with. Detail the role of the trainee in the proposed
research project and how it links to the supervisor’s research program and/or research group. Do not exceed space below.




Application - 9                          Graduate Studentship 201210
                                                                                                     APPLICANT NAME
5.        MENTORING PLAN
The Primary Research Supervisor and Co-Mentor TO DISCUSS MENTORING ENVIRONMENT.
Describe in specific detail how the proposed mentorship advisors will benefit the research training, and career and professional
development of the applicant. Provide information regarding the specific plans for the interactions of the mentorship advisors
and the trainee and how the mentoring plan connects to the career development plan of the applicant. Do not exceed space
below.




Application - 10                       Graduate Studentship 201210
                                                                                                APPLICANT NAME

6.        RESEARCH CLASSIFICATION

     A. Area of Strategic Focus (Alberta Health Research & Innovation Strategy): (Select all that may apply):

         Child & Maternal Health                   Mental Health & Addictions            Chronic Disease


         Infectious Disease                        Health Promotion                      Vulnerable Populations


         Injury prevention, Acute care            Environmental Health                   Effectiveness & Efficiency
         & Rehabilitation                                                                (Health Services)


         Innovative Delivery Models                Chronic Disease Management            Personalized Medicine
         (Health Services)                         Support Systems (Health Services)     (Health Services)




Application - 11                         Graduate Studentship 201210
                                                                                                APPLICANT NAME

RESEARCH CLASSIFICATION (cont.)
B. Area of Research Classification by discipline (Enter up to three disciplines):

    Anatomy                                                        Nuclear Medicine

    Anesthesia                                                     Nursing

    Biochemistry                                                    Obstetrics and Gynecology

    Biomedical Engineering and Biochemical Engineering             Occupational Therapy

    Cardiology                                                     Oncology

    Cell Biology                                                   Ophthalmology

    Chiropractic                                                   Optometry

    Dentistry                                                      Orthopedics

    Dermatology                                                    Pathology

    Dietetics and Nutrition                                        Pediatrics

    Endocrinology                                                  Pharmacology

    Epidemiology and Biostatics                                    Pharmacy

    Ergonomics                                                     Physiatry

    Family Medicine                                                Physical Education

    Gastroenterology                                                Physiology

    Genetics                                                       Physiotherapy

    Geriatrics-Gerontology                                         Pneumology

    Health Administration                                          Preventive and Community Medicine

    Hematology                                                     Psychiatry

    Immunology                                                      Radiology

    Kinanthropology                                                Rheumatology

    Kinesiology                                                    Speech-Language Pathology and Audiology

    Microbiology                                                   Surgery

    Molecular Biology                                              Urology

    Nephrology                                                     Virology

    Neurosciences                                                  Water and Environment




Application - 12                     Graduate Studentship 201210
                                                                                                    APPLICANT NAME

PROJECT TITLE


7.        LAY SUMMARY
Applicant is to provide a lay summary of the research proposal in non-scientific, everyday language that would be accessible to
a general audience. Use analogies, simplifications, and generalizations rather than scientific and technical terms. Do not
exceed space below.




Application - 13                      Graduate Studentship 201210
                                                                                                 APPLICANT NAME

8.        PROPOSED RESEARCH PROJECT
The applicant is to provide a detailed description of the proposed research project for the period during which the award is to be
held. Background information should indicate the position and significance of the proposed research within the context of the
current knowledge of the field. The research plan outlining the proposed project should state the specific objectives; outline the
methodological approach; and the defined key milestones or deliverables to be achieved. Do not exceed space below.




Application - 14                       Graduate Studentship 201210

								
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