FHI 360-UNC Public Health Fellowship Application. Due Date: Thursday, January 22, 2015

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1 FHI 360-UNC Public Health Fellowship Application Due Date: Thursday, January 22, 2015 FHI 360 s mission is to improve lives worldwide by addressing complex public health issues through research, education and services. Since our inception in 1971, FHI 360 has formed partnerships with national governments and local communities in more than 100 countries throughout the developing world to support lasting improvements in the health of individuals and the effectiveness of entire health systems. AA/EEO/M/F/V/D. Please complete this application, then sign and date your Applicant Certification and Acceptance statement. Please submit all materials electronically to the Gillings Global Gateway at globalgateway@unc.edu. Hard copies (e.g. letters of recommendation, unofficial transcripts) can be sent to Gillings Global Gateway, 104 Rosenau Hall, CB#7400, UNC Gillings School of Global Public Health, Chapel Hill, NC Attach the following as a supplement to this application: -Resume or CV -Unofficial Transcript (if new PhD student, transcript from previous graduate work) -Recommendations from a former employer and a faculty member with whom you have an established relationship (current or past). Personal Last Name First Middle Daytime/Evening Phone Number Street Address City, State, Zip Code Address I am applying for the FHI 360 Fellowship Program Are you legally eligible to work in the United States? Yes No Citizenship Status (check one) U.S. Permanent Resident Student Visa; Type Proof of your identity and eligibility will be required. LANGUAGE PROFICIENCY (Please Mark X in boxes that apply) Language Speaking Reading Writing Comprehension Fair Good Exc. Fair Good Exc. Fair Good Exc. Fair Good Exc. GENERAL EDUCATION LEVEL Name and Location of School Undergraduate Course of Study No. Years Comple ted Did you Graduate? Degree/Diploma Graduate Graduate Other

2 1A: Summarize your previous relevant research experiences (domestic and international). Please limit your response to 300 words or less. FHI 360-UNC Fellowship 5 November 2014 Page 2 of 5

3 1B. Please indicate with an X which areas are strengths, and in which areas you would like to expand your skill set. RESEARCH DOMAIN STRENGTH/EXPERTISE? HIGHEST PRIORITY FOR GAINING EXPERIENCE (CHOOSE TOP 3) QUALITATIVE 1. Study implementation 2. Data entry/cleaning 3. Research design 4. Protocol writing 5. Data coding 6. Data analysis 7. Manuscript preparation QUANTITATIVE - 1. Study implementation 2. Data entry/cleaning 3. Research design 4. Protocol writing 5. Data coding 6. Data analysis 7. Manuscript preparation FHI 360-UNC Fellowship 5 November 2014 Page 3 of 5

4 2. Please describe your post-graduate career plans, specifically, how you think an FHI 360 fellowship will strengthen your career plans. Please limit your response to 300 words or less. FHI 360-UNC Fellowship 5 November 2014 Page 4 of 5

5 3. List all current and anticipated funding or scholarships obtained for research and your degree program (include award dates and institution). 4. Please list computer software for which you are proficient (ex. SAS, STATA, etc.). APPPLICANT CERTIFICATION AND ACCEPTANCE: I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the statements and answers on this application and supporting materials. I am aware that FHI 360 s consideration of this application may include an investigation regarding any and all statements and answers made, and I hereby consent to such investigation. I am aware that should an investigation disclose any misrepresentation, omissions, or falsification, my application will be rejected, or if I am already employed, my employment may be terminated. FHI 360 reserves the right to terminate employees without prior notice. Signature: Date: FHI 360-UNC Fellowship 5 November 2014 Page 5 of 5

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