CMB Global Health Leadership Development Program
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Online Application Form
Please fill in this online form in
English
, unless otherwise specified.
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Family Name
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Given Name
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Full name in Chinese
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Year of Birth
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Gender
Male
Female
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The highest degree obtained
PhD
MD
DPH
Master
Bachelor
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The major/subject of your highest degree
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The year of the highest degree obtained
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Cell-phone number
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Preferred contact email address
Secondary contact email address
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Please choose your current profession from the categories below
Faculty member working in university in China
Health professional or researcher working in CDC or other research institutions
Official working in Chinese governmental agencies
Clinical practitioner working in healthcare institution in China
Chinese student studying at a Chinese university
Chinese student studying at an university outside China
Professional from the biopharmaceutical and other related enterprises
Others (Please specify)
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Current academic/professional/administration title
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Current affiliation
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Full address of current affiliation
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School and/or Department in current affiliation
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Your specialized area in global health
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Demonstration of competence in English (if any)
【多选题】
IELTS (please specify when you took the test and the specific scores obtained)
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TOFEL (please specify when you took the test and the specific scores obtained)
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Other English language test (please specify when and what test you took, and results obtained)
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Degree obtained or to be obtained in English-speaking country (please specify)
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Work/study experience in English-speaking country (please specify)
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Others (please specify)
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Competence in other foreign languages
Yes (if yes, please specify)
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No
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You'd like to apply to the CMB Global Health Leadership Development Program through which program operating institution?
Yale School of Medicine
London School of Hygiene and Tropical Medicine
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Which LMIC sites are you interested in to conduct your fellowship project?
(Please choose no more than three, in the order of 1st choice, 2nd choice and 3rd choice)
【
最多
选择3项并排序】
Center of Excellence on Research in AIDS, University of Malaya, Malaysia
Yale-Samoa Ministry of Health Collaborative Research Center, Samoa
University of Ghana Medical and Dental School, Ghana
University of KwazuluNatal, South Africa
University of Cheikh Anta Diop/Hôpital Aristide Le Dantec, Senegal
Sudan
Chad
Kenyatta National Hospital, Kenya
Universidad Peruana Cayetano Heredia, Peru
Centro Internacional de Entrenamiento e Investigaciones Medicas,Columbia
Oswaldo Cruz Foundation, Brazilian Ministry of Health, Brazil
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Which LMIC sites are you interested in to conduct your fellowship project?
(Please choose no more than three, in the order of 1st choice, 2nd choice and 3rd choice)
【
最多
选择3项并排序】
Biomedical Research and Training Institute, Zimbabwe
Cancer Survival Group, Brazil and the Russian Federation
Clinical Trials Unit, International
Faculty of Medicine, Chiang Mai University, Thailand
Health Intervention and Technology Assessment Agency, Thailand
Institute of Medical Research, Nigeria
National Institute of Nutrition, India
Social Innovation in Health Initiative, Philippines
The MRC Unit, Gambia
Sangath, India
Information on two referees
(the two people who will write letters of recommendation for you; at least one of them should be your current supervisor or mentor in your home institution)
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Full name of your first referee
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Title
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Affiliation
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Relationship to applicant
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E-mail
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Full name of your second referee
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Title
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Affiliation
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Relationship to applicant
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E-mail
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In addition to the Yale/LSHTM mentor and the LMIC site mentor, do you plan to have a third mentor from a Chinese institution?
Yes
No
Undecided
Please provide the information of your potential mentor from the Chinese institution to join the co-mentor team for your fellowship training.
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Full name
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Title
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Affiliation
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Relationship to you
How did you hear about this program?
Through colleague or friend
Through supervisor or mentor
Social media
CMB or Yale or LSHTM website
Program promotion event
Search engine (Google, Baidu, etc.)
Other (please specify)
标题
*
Do you have any global health realted work or study experience at abroad (outside China)?
Yes
No
Please provide information for your up to five most important global health related work or study experience at abroad.
百度
谷歌
搜狗
外观
功能
Please provide the information about your up to five most important global health related work or study experiences at abroad.
Country and location
Duration (start & end date)
Program/project name
Your position/title
Your responsibilities/activities
Deliverables/outcomes
Sponsoring organization
1
2
3
4
5
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How did you hear about this CMB Global Health Leadership Development Program?
Through colleague or friend
Through supervisor or mentor
Social media
CMB or Yale or LSHTM website
Program promotion event
Search engine (such as Google, Baidu, etc)
Other (please specify)
*
评价对象得分
(?)
A.男
B.女
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