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					   CLINICIAN SCIENTIST (post-MD degree)
TRANSPLANTATION FELLOWSHIP MODULE

                     COMPETITION 2008
                CLINICIAN SCIENTIST (post-MD degree) TRANSPLANTATION FELLOWSHIP
                                        COMPETITION 2008


Candidate
Surname                                                              Given Name
Project Title



Location where research will be conducted
Institute                                     Department                                     Faculty




Institute which will administer the funds (Name, address and telephone number of administrative officer)


Primary Supervisor
Surname                                                              Given Name

Secondary Supervisor
Surname                                                              Given Name
Citizenship
Canadian                                    Permanent Resident                         Other            Country

Language in which the proposal is written                      Period of support requested

                   English             French                                                       2 Years           3 years

Have you applied to the CSTF program before?         YES              Year of Competition

                                                     NO
Signatures
It is agreed that the general conditions governing grants and awards as outlined in the Guidelines and Regulations apply to any grant or
award made pursuant to this application and are hereby accepted by the applicant(s) and the applicant’s employing institution.

Primary Supervisor                            Secondary Supervisor                           Head of Department at Proposed
                                                                                             Training Location
Name and Address                              Name and Address                               Name and Address




Signature                                     Signature                                      Signature

Date                                          Date                                           Date

Candidate

Name        _____________________________            Signature ____________________________               Date____________________



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Name of Candidate


Themes
Indicate a primary theme classification by typing in the number 1 next to the selected theme. Indicate a second, third and fourth theme
classification only where the substance of the award application significantly overlaps more than one theme (use numbers 2, 3 and 4 to
indicate the selections in order of importance)

         Biomedical Research

         Clinical Research

         Research respecting health systems and health services

         Research on societal, cultural and environmental influences on health and the health of populations

Choose appropriate category for this proposal (only one category)

Heart
Kidney
Liver
Lung
Organ Donation


Indicate if the project involves
         Human Subjects                      YES          NO

         Animal Care Form                    YES          NO

         A requirement for containment       YES          NO            Level 1         2        3        4

         Human Stem Cell Research            YES          NO

ALL APPLICABLE CERTIFICATES MUST BE PROVIDED TO THE CLINICIAN SCIENTIST (POST-MD DEGREE)
TRANSPLANTATION FELLOWSHIP PROGRAM AT THE LATEST MAY 1, 2008


Descriptors
Provide a maximum of 10 keywords to describe this research project, the techniques to be employed and the disease(s), which will be
impacted by this research.




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Name of Candidate


DEGREE IN PROGRESS
Degree Type       Degree Name                           Department          Institution                  Start Date        Expected Date
                                                                                                        (MM/YYYY)          of Completion
                                                                                                                            (MM/YYYY)




Qualifications, certificates and licenses in progress                                                    Start Date        Expected Date
                                                                                                        (MM/YYYY)          of Completion
                                                                                                                            (MM/YYYY)




With this award are you proceeding or planning to proceed to any additional degree, diploma and specialty certification?

           NO               YES        (please specify)

DEGREE SOUGHT
Degree Type               Degree Name                   Department          Institution                  Start Date        Expected Date
                                                                                                        (MM/YYYY)          of Completion
                                                                                                                            (MM/YYYY)




Training
Indicate the expected duration of the proposed training

Training (clinical and research) to be completed
                                                          (MM/YYYY)

Is it your intention to obtain a permanent position in Canada?        YES          NO




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Name of Candidate


Only to be completed by candidates proposing training outside Canada:

Is it your intention to obtain a permanent position in Canada as a research scientist?       YES           NO

Please describe the factors that have influenced your decision :




Have you been offered a permanent position?                          YES          (Please attach proof)    NO
Sponsors
Candidates must ask three individuals to provide assessments on their behalf. Use the appropriate CLINICIAN SCIENTIST (post-MD
degree) TRANSPLANTATION FELLOWSHIP forms. Additional assessments will not be considered. These should include (if
applicable) assessments from each of your two most recent research supervisors. For Post doctoral Fellowship candidates, one of
these assessments should be from your PhD supervisor (if applicable). Give the names of the individuals whose assessments
accompany this application.

           Name of Sponsor /
                                                          Current Position Held                           Institution
        Relationship to Candidate
1.



Attached                   To be forwarded
2.




Attached                   To be forwarded
3.



Attached                   To be forwarded




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Name of Candidate


Training Expectations
Provide an overview of your reasons for applying to the CLINICIAN SCIENTIST TRANSPLANTATION FELLOWSHIP and how you
think the CLINICIAN SCIENTIST TRANSPLANTATION FELLOWSHIP will help you in establishing an independent research career
(including your long-term career goals and relevance to transplantation). Please include in your answer how your research program will
lend itself to translational initiatives involving other solid organs as well as other research themes (e.g. biomedical research, clinical
research, research respecting health systems and heath services, and research on societal, culture and environmental influences of
health and the health of populations). Describe how the training you expect to acquire will contribute to your future achievements and
productivity and the formation of research teams or networks. Make sure to include a description of your research environment. Two
additional pages may be added




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Name of Candidate


Proposed Training Program
This section should be completed in collaboration with the proposed supervisor. Both you and your supervisor should sign at the
bottom of page 7 to confirm the accuracy of the proposed training program.

Project Title


Summary of Research Project
Include specific research hypotheses and describe the candidate’s own role in the project. This summary should be written in general
scientific language. One additional page may be added.




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Name of Candidate


Describe the space, facilities and personnel support, which will be available to the candidate. No additional pages may be added.




The CLINICIAN SCIENTIST (post-MD degree)TRANSPLANTATION FELLOWSHIP requires that 80% of the candidate’s time and
effort will be devoted to the research project and clinical activities upon which the research project(s) are immediately dependant.
Describe all the activities undertaken by the candidate other than direct work on the proposed research project (e.g. teaching courses,
supervision, seminars, and clinical activities). Indicate the percentage of time to be spent on each activity using whatever timeframe (i.e.
per week, month, and year) that best describes the involvement.




THIS SUMMARY OF THE RESEARCH PROJECT WAS WRITTEN BY:

Candidate                   Proposed Supervisor(s)                      Both
THE UNDERSIGNED AGREE THAT THIS ACCURATELY DESCRIBES THE TRAINING PROGRAM PROPOSED.
Primary Supervisor                Secondary Supervisor             Candidate




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Name of Candidate


Lay Title (one line only)


Lay Summary (suitable for preparation of a press release)
Suitable for non-scientific audience publication (e.g. the partners web sites or preparation of a press release). Summarize in general
terms why the research is important, what disease may be impacted and what results are expected. No additional pages may be
added.




_________________________________________________________________________________________________________________________
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       APPENDIX A – SPONSOR’S ASSESSMENT OF A CANDIDATE FOR A POST DOCTORAL FELLOWSHIP



Name of Candidate


Name of Sponsor


Relationship to Candidate


Sponsor’s Title, Department and Institution


Notes
   The Canadian Privacy Act stipulates that, in response to a specific request by the candidate, the Clinician Scientist (post-MD
    degree) Transplantation Fellowship secretariat must make available a copy of your assessment.
   The text boxes in this form will expand to accommodate your requirements for writing space.
SECTION 1: CONTEXT FOR YOUR OBSERVATIONS ON THE CANDIDATE
For how many years have you known the candidate?




Describe the situation(s) in which you have had an opportunity to interact with the candidate. (One paragraph only, please.)
Context for observations on the candidate:




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SECTION 2: ASSESSMENT OF POTENTIAL
Provide your perspective on the candidate’s potential to become a highly productive, independent researcher. Maximum one
paragraph. Overall appreciation of the candidate’s potential for independent research.




SECTION 3: YOUR PERSPECTIVE ON THE CANDIDATE’S DEMONSTRATION OF SPECIFIC CHARACTERISTICS
A. Describe evidence that the candidate has demonstrated independence and capacity for critical thought. Related concepts include
intellectual curiosity, inventiveness, analytical capacity and leadership. Maximum two paragraphs.
Candidate’s demonstration of independence and capacity to think critically:




Rate the candidate’s independence and capacity with reference to the broad descriptions that are provided.
                                        Rating of candidate’s independence and capacity to think critically
    Average or lower in      Above average in strength
                                                               Strong and frequently          Very strong and very    Exceptionally strong and
 strength and frequency of       and frequency of
                                                                   demonstrated             frequently demonstrated    always demonstrates
       demonstration              demonstration
         0 to 2.9                    3.0 to 3.4                     3.5 to 3.9                      4.0 to 4.4               4.5 to 4.9



                                                  Insert rating number, not a checkmark, please.
B. Describe evidence that the candidate has demonstrated a capacity to pursue knowledge energetically and with clarity of objectives.
Related concepts include organization, determination, initiative and patience. Maximum two paragraphs.
Candidate’s demonstration of energetic and focused pursuit of knowledge:




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Rate the candidate’s capacity for energetic and focused pursuit of knowledge with reference to the broad descriptions that are provided.
                                   Rating of candidate’s capacity for energetic and focused pursuit of knowledge
    Average or lower in       Above average in strength
                                                                 Strong and frequently            Very strong and very    Exceptionally strong and
 strength and frequency of        and frequency of
                                                                     demonstrated               frequently demonstrated    always demonstrates
       demonstration               demonstration
         0 to 2.9                     3.0 to 3.4                        3.5 to 3.9                        4.0 to 4.4             4.5 to 4.9



                                                       Insert rating number, not a checkmark.
C. Describe evidence that the candidate has demonstrated creative thinking. If they have had an opportunity to conduct research,
please refer to their creativity in setting research goals, designing experiments, developing new methodologies, interpreting findings
and presenting results in writing. Maximum two paragraphs.
Candidate’s demonstration of creative thinking:




Rate the candidate’s capacity for creative thinking with reference to the broad descriptions that are provided.
                                                   Rating of candidate’s capacity for creative thinking
    Average or lower in       Above average in strength
                                                                 Strong and frequently            Very strong and very    Exceptionally strong and
 strength and frequency of        and frequency of
                                                                     demonstrated               frequently demonstrated    always demonstrates
       demonstration               demonstration
         0 to 2.9                     3.0 to 3.4                        3.5 to 3.9                        4.0 to 4.4             4.5 to 4.9



                                                       Insert rating number, not a checkmark.
SECTION 4: YOUR VIEW OF THE CANDIDATE’S MOST SIGNIFICANT ACHIEVEMENT
Indicate the candidate’s most significant achievement to date. If the candidate has had an opportunity to conduct research, you should
describe their most significant research contribution.
Candidate’s most significant achievement:




SECTION 5: YOUR SIGNATURE
Sponsor’s signature                                                           Date



SECTION 6: TRANSMITTAL OF THE COMPLETED REPORT
  You should send your report to the candidate in a sealed envelope; inscribe your signature across the seal.
  Please bear in mind that the candidate will need to assemble a complete application package, including this report, by the
   competition deadline.
   The CLINICIAN SCIENTIST (post-MD degree) TRANSPLANTATION FELLOWSHIP program will not consider late or
   incomplete applications.




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Name of Candidate



                                                         MEDIA GUIDELINES

The Clinician Scientist Transplantation Fellowship recipients and supervisor must advise the Director of The Kidney Foundation
of Canada of any proposed activities that may have media relations implications related to the work supported by the Clinican
Scientist Transplantation Fellowship. Copies of the relevant materials (i.e. media releases, media backgrounders, etc.) should be
submitted to the Director, Research Program for approval in advance of the activity to:

                                                Director National Research Program
                                                 The Kidney Foundation of Canada
                                                   300-5165 Sherbrooke St. West
                                                    Montreal, Quebec H4A 1T6

The above would not apply to papers presented at various scientific meetings, or when there is casual discussion with the news media
on matters not related to the Clinician Scientist Transplantation Fellowships.

                 APPLICANT CONSENT FORM FOR USE AND DISCLOSURE OF PERSONAL INFORMATION
               PROVIDED TO THE CLINICIAN SCIENTIST TRANSPLANTATION FELLOWSHIP FOR PEER REVIEW

The Clinician Scientist Transplantation Fellowship seeks your certification that you have been informed that all the information
supplied in this application will be made available to Clinician Scientist Transplantation Felllowship program and partner personnel
responsible for managing the peer review process to review applications, to administer and monitor grants and awards, to compile
statistics and to promote kidney research in Canada.

Information supplied in the application will be made available to Peer Review Committees composed of experts recruited from the
academic, public and private sectors. Applications may also be transmitted to external reviewers.

Information supplied in the application may also be made available to the prtners for relevancy and funding decisions.

I, the undersigned, do hereby give CONSENT to the use and disclosure of the information contained in my application for the purposes
as described in the Clinician Scientist Transplantation Fellowship guidelines. I understand that I may withdraw my consent at any
time and that it will become effective upon its receipt by the Clinician Scientist Transplantation Fellowship. Further, I agree to the
Media Guidelines should I be awarded a Clinician Scientist Transplantation Fellowship.


Signatures                                                                                 Date


Candidate




Supervisor




Do you agree to the release of the information on page 1, the summary of research and lay abstract to other
organizations for the purpose of determining potential eligibility for other sources of funding?

         YES               NO


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