Form 1 Application for International Research and Fellowship Aw

Attachment 1 –
Form- Application

OMB #0925-xxxx
Expiration date mm/dd/yyyy
Public reporting burden for this collection of information is estimated to take 60 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20902-7974, ATTN:PRA
(0925-xxxx). Do not return the completed form to this address.

International Research and Fellowship Award Program Application
Post-Doctoral Applicant

Professional Development Applicant

(English Language Only)

Part I—Applicant Information
1. First/Given Name of Applicant:
2. Last/Family Name of Applicant:
3. Country of Citizenship (if dual citizenship, list both):
4. Year of Birth (yyyy):
5. Advanced Degree(s):
6. Position Title:
7. Name of Institution:
8. Department, Division, Service, Laboratory:
9. Institution Mailing Address (street address, city, state, postal code):
10. Country:
11. Office Phone (country code, city code, number):
12. Office Fax (country code, city code, number):
13. Office E-mail:
14. Permanent Home Address (street address, city, country, postal code):
15. Home Phone (country code, city code, number):

16. Alternative E-mail:

Applicant Certification and Acceptance
I certify that the statements herein are true, complete, and accurate to the best of my knowledge, and accept the obligation
to comply with terms and conditions if a fellowship is awarded as a result of this application. I am aware that any false,
fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.
 I have read and understand the application requirements and the fellowship policies and procedures.
Applicant’s Signature ____________________________________________ Date

Applicant Last/Family Name:

Mentor Last/Family Name:

Part II—Application Checklist
To ensure that all documents supporting the fellowship application are properly completed and included with your
application, please check the appropriate items listed below and return this checklist with your application. Only
COMPLETE applications will be reviewed.
1. Applicant To Complete and/or Provide the Following:
Form Part I and sign Certification and Acceptance Statement
Form Part III—Applicant Section
Form Parts IV, V, and VI
Form Part VI—Research Proposal
Reference have been requested from [must be two]:
1.

(Full Name of Supervisor/Colleague)

2.

(Full Name of Colleague/Supervisor)

Certification of doctoral degree(s) (including English translation if necessary)
List of peer-reviewed publications
Appendix (optional): Applicants who have authored or coauthored articles in peer-reviewed scientific journals may
submit a maximum of three publications.
2. Mentor To Complete and/or Provide the Following:
Form Part II and sign Certification and Acceptance Statement
Form Part III—Mentor Section
Form Parts VIII, IX, and X
Form Part X and obtain necessary institution signatures as indicated
Applicant With U.S. Mentor: Letter from U.S. mentor’s institution representative confirming institution as a
sponsor for the U.S. Department of State “J” Exchange Visitor Program and the institution’s eligibility to prepare
and issue the requisite Form DS-2019 for the applicant and his/her dependents.

Applicant Last/Family Name:

Mentor Last/Family Name:

Part III—Applicant’s Education and Training History
Add an additional page if more space is needed.
1. Education—List all postsecondary institutions you attended, beginning with the most recent.
a) Name and Location of Institution:
Major Field(s) of Study:
Begin and End Dates of Attendance (Month, Year to Month, Year):

to

Name of Diploma or Degree:
Date Diploma/Degree Received (Month, Year):
Title(s) of Theses/Dissertations (if any):
b) Name and Location of Institution:
Major Field(s) of Study:
Begin and End Dates of Attendance (Month, Year to Month, Year):

to

Name of Diploma or Degree:
Date Diploma/Degree Received (Month, Year):
Title(s) of Theses/Dissertations (if any):
c) Name and Location of Institution:
Major Field(s) of Study:
Begin and End Dates of Attendance (Month, Year to Month, Year):

to

Name of Diploma or Degree:
Date Diploma/Degree Received (Month, Year):
Title(s) of Theses/Dissertations (if any):
d) Name and Location of Institution:
Major Field(s) of Study:
Begin and End Dates of Attendance (Month, Year to Month, Year):
Name of Diploma or Degree:
Date Diploma/Degree Received (Month, Year):
Title(s) of Theses/Dissertations (if any):

to

Applicant Last/Family Name:

Mentor Last/Family Name:

Part IV—Applicant’s Education and Training History (continued)
Add an additional page if more space is needed.
2. Additional Training
List any relevant training completed, beginning with the most recent; include U.S. National Institutes of Health
sponsored activities or funding.
a) Activity/Event:
Topic Field:
Institution Host/Sponsor:
Begin and End Dates of Attendance (Month, Year to Month, Year):

to

b) Activity/Event:
Topic Field:
Institution Host/Sponsor:
Begin and End Dates of Attendance (Month, Year to Month, Year):

to

c) Activity/Event:
Topic Field:
Institution Host/Sponsor:
Begin and End Dates of Attendance (Month, Year to Month, Year):

to

3. List your 5 to 10 most relevant peer-reviewed publications.

4. List your significant honors, awards, projects, or other accomplishments.

Applicant Last/Family Name:

Mentor Last/Family Name:

Part V—Applicant’s Current and Previous Employment
Add an additional page if more space is needed.
1. List Your Current Employment.
a) Name Current Employer:
City and Country of Current Employer:
Institution Type (public or private - university, college, hospital, etc.):
Current Job Title:
Begin Date of Employment (Month, Year):
End Date of Employment (Month, Year) if applicable:
Describe your current job responsibilities:
b) Name Additional Current Employer (if any):
City and Country of Current Employer:
Institution Type (public or private - university, college, hospital, etc.):
Current Job Title:
Begin Date of Employment (Month, Year):
End Date of Employment (Month, Year) if applicable:
Describe your current job responsibilities:

2. Previous Employment.
a) Employer/Hosting Institution:
Job/Position Title:
Begin and End Date(s) (Month, Year to Month, Year):

to

Primary job/position responsibilities:
b) Employer/Hosting Institution:
Job/Position Title:
Begin and End Date(s) (Month, Year to Month, Year):

to

Primary job/position responsibilities:
c) Employer/Hosting Institution:
Job/Position Title:
Begin and End Date(s) (Month, Year to Month, Year):
Primary job/position responsibilities:

to

Applicant Last/Family Name:

Mentor Last/Family Name:

Part VI—Applicant’s Travel Information
When listing first/given and last/family names, include all names as appear on the passport
First/Given Name:
Last/Family Name:
Year of Birth (yyyy):
Nationality (listed on passport):
Gender:
Passport Issued:
No
Application Pending
Issuing Country:

Yes, Expiration Year (yyyy):

Traveling with Applicant during Fellowship:
First/Given Name:
Last/Family Name:
Relationship to Applicant (spouse, child, etc.):
Year of Birth (yyyy):
Nationality (listed on passport):
Gender:
Passport Issued:
No
Application Pending
Issuing Country:
First/Given Name:
Last/Family Name:
Relationship to Applicant (spouse, child, etc.):
Year of Birth (yyyy):
Nationality (listed on passport):
Gender:
Passport Issued:
No
Application Pending
Issuing Country:
First/Given Name:
Last/Family Name:
Relationship to Applicant (spouse, child, etc.):
Year of Birth (yyyy):
Nationality (listed on passport):
Gender:
Passport Issued:
No
Application Pending
Issuing Country:

Yes, Expiration Year (yyyy):

Yes, Expiration Year (yyyy):

Yes, Expiration Year (yyyy):

Applicant Last/Family Name:

Mentor Last/Family Name:

Part VII—Applicant’s Research Proposal
Add an additional page if more space is needed.

2. List the research subject discipline:
Note: Discipline is the general category which best describes the subject of your research proposal and under which
your proposal will be reviewed.

3. Research Proposal Title:
Note: The title should be as informative as possible, capturing the essence of the research (e.g., country of research,
objective). Please outline the intersection between drug use (e.g., alcohol, cocaine, heroin) and HIV that you plan to
study.

4. Country where research will be conducted:
5. Fellowship Goals
a) Provide a 75-word summary of your goals for the fellowship.

b) Describe the potential impact of the fellowship on your career goals and the capacity building in your home
country (maximum 200 words).

6. Research Proposal Abstract—Limit your abstract to 300 words.
Note: Summarize your planned research project. Keep in mind that the research proposal needs to be related to drug
use (e.g., alcohol, cocaine, heroin) and HIV. What are the objectives of the study? Why is the study important? What
are the key assumptions? What methods will be used to achieve the objectives?

Applicant Last/Family Name:

Mentor Last/Family Name:

Part VII—Applicant’s Research Proposal (continued)
Add an additional page if more space is needed.

7. Applicant’s Full Research Plan.
Note: Only research plans written in English will be reviewed.
a) Specific Aims (maximum 440 words)
Note: The aims must be precise and measurable. Keep in mind that your aims will be used to measure the
successful completion of your research project

b) Background and significance (maximum 440 words)
Note: Provide all necessary information to fully understand the rationale and the significance of the proposed
study

c) Research design and methods (maximum 1400 words)
Note: Discuss and provide detailed information about the research design and specific methodology used to
achieve the specific aims of the proposed study

d) Sex and gender consideration (maximum 440 words)
Note: Describe in detail how your research design takes sex (biological) and gender (socio-cultural) considerations
into account and how the results of your study will be analyzed accordingly.

e) Expected Outcomes (maximum 440 words)
Note: When discussing outcomes you may want to answer such questions as ‘Who are the beneficiaries of the
research?’ ‘How can the research be translated into improved practice and policy?’ ‘How can the research
contribute to broader scientific efforts within the field?’

c) Literature citations (maximum 600 words)
Note: List all references used in the proposal. All listings must be complete and contain the author(s), title of the
article, name of the journal, year and month of the publication, and publication information.

WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects
http://www.wma.net/en/30publications/10policies/b3/
Adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964 and amended by the: 29th WMA General
Assembly, Tokyo, Japan, October 1975, 35th WMA General Assembly, Venice, Italy, October 1983, 41st WMA General
Assembly, Hong Kong, September 1989, 48th WMA General Assembly, Somerset West, Republic of South Africa,
October 1996, 52nd WMA General Assembly, Edinburgh, Scotland, October 2000, 53rd WMA General Assembly,
Washington DC, USA, October 2002 (Note of Clarification added), 55th WMA General Assembly, Tokyo, Japan,
October 2004 (Note of Clarification added), 59th WMA General Assembly, Seoul, Republic of Korea, October 2008, 64th
WMA General Assembly, Fortaleza, Brazil, October 2013
Preamble
1. The World Medical Association (WMA) has developed the Declaration of Helsinki as a statement of ethical principles
for medical research involving human subjects, including research on identifiable human material and data. The
Declaration is intended to be read as a whole and each of its constituent paragraphs should be applied with consideration
of all other relevant paragraphs.
2. Consistent with the mandate of the WMA, the Declaration is addressed primarily to physicians. The WMA encourages
others who are involved in medical research involving human subjects to adopt these principles.
General Principles
3. The Declaration of Geneva of the WMA binds the physician with the words, “The health of my patient will be my first
consideration,” and the International Code of Medical Ethics declares that, “A physician shall act in the patient's best
interest when providing medical care.”
4. It is the duty of the physician to promote and safeguard the health, well-being and rights of patients, including those
who are involved in medical research. The physician's knowledge and conscience are dedicated to the fulfilment of this
duty.
5. Medical progress is based on research that ultimately must include studies involving human subjects.
6. The primary purpose of medical research involving human subjects is to understand the causes, development and
effects of diseases and improve preventive, diagnostic and therapeutic interventions (methods, procedures and treatments).
Even the best proven interventions must be evaluated continually through research for their safety, effectiveness,
efficiency, accessibility and quality.
7. Medical research is subject to ethical standards that promote and ensure respect for all human subjects and protect their
health and rights.
8. While the primary purpose of medical research is to generate new knowledge, this goal can never take precedence over
the rights and interests of individual research subjects.
9. It is the duty of physicians who are involved in medical research to protect the life, health, dignity, integrity, right to
self-determination, privacy, and confidentiality of personal information of research subjects. The responsibility for the
protection of research subjects must always rest with the physician or other health care professionals and never with the
research subjects, even though they have given consent.
10. Physicians must consider the ethical, legal and regulatory norms and standards for research involving human subjects
in their own countries as well as applicable international norms and standards. No national or international ethical, legal or
regulatory requirement should reduce or eliminate any of the protections for research subjects set forth in this Declaration.
11. Medical research should be conducted in a manner that minimises possible harm to the environment.
12. Medical research involving human subjects must be conducted only by individuals with the appropriate ethics and
scientific education, training and qualifications. Research on patients or healthy volunteers requires the supervision of a
competent and appropriately qualified physician or other health care professional.
13. Groups that are underrepresented in medical research should be provided appropriate access to participation in
research.

14. Physicians who combine medical research with medical care should involve their patients in research only to the
extent that this is justified by its potential preventive, diagnostic or therapeutic value and if the physician has good reason
to believe that participation in the research study will not adversely affect the health of the patients who serve as research
subjects.
15. Appropriate compensation and treatment for subjects who are harmed as a result of participating in research must be
ensured.
Risks, Burdens and Benefits
16. In medical practice and in medical research, most interventions involve risks and burdens. Medical research involving
human subjects may only be conducted if the importance of the objective outweighs the risks and burdens to the research
subjects.
17. All medical research involving human subjects must be preceded by careful assessment of predictable risks and
burdens to the individuals and groups involved in the research in comparison with foreseeable benefits to them and to
other individuals or groups affected by the condition under investigation. Measures to minimise the risks must be
implemented. The risks must be continuously monitored, assessed and documented by the researcher.
18. Physicians may not be involved in a research study involving human subjects unless they are confident that the risks
have been adequately assessed and can be satisfactorily managed. When the risks are found to outweigh the potential
benefits or when there is conclusive proof of definitive outcomes, physicians must assess whether to continue, modify or
immediately stop the study.
Vulnerable Groups and Individuals
19. Some groups and individuals are particularly vulnerable and may have an increased likelihood of being wronged or of
incurring additional harm. All vulnerable groups and individuals should receive specifically considered protection.
20. Medical research with a vulnerable group is only justified if the research is responsive to the health needs or priorities
of this group and the research cannot be carried out in a nonvulnerable group. In addition, this group should stand to
benefit from the knowledge, practices or interventions that result from the research.
Scientific Requirements and Research Protocols
21. Medical research involving human subjects must conform to generally accepted scientific principles, be based on a
thorough knowledge of the scientific literature, other relevant sources of information, and adequate laboratory and, as
appropriate, animal experimentation. The welfare of animals used for research must be respected.
22. The design and performance of each research study involving human subjects must be clearly described and justified
in a research protocol. The protocol should contain a statement of the ethical considerations involved and should indicate
how the principles in this Declaration have been addressed. The protocol should include information regarding funding,
sponsors, institutional affiliations, potential conflicts of interest, incentives for subjects and information regarding
provisions for treating and/or compensating subjects who are harmed as a consequence of participation in the research
study. In clinical trials, the protocol must also describe appropriate arrangements for post-trial provisions.
Research Ethics Committees
23. The research protocol must be submitted for consideration, comment, guidance and approval to the concerned research
ethics committee before the study begins. This committee must be transparent in its functioning, must be independent of
the researcher, the sponsor and any other undue influence and must be duly qualified. It must take into consideration the
laws and regulations of the country or countries in which the research is to be performed as well as applicable
international norms and standards but these must not be allowed to reduce or eliminate any of the protections for research
subjects set forth in this Declaration. The committee must have the right to monitor ongoing studies. The researcher must
provide monitoring information to the committee, especially information about any serious adverse events. No
amendment to the protocol may be made without consideration and approval by the committee. After the end of the study,
the researchers must submit a final report to the committee containing a summary of the study’s findings and conclusions.
Privacy and Confidentiality

24. Every precaution must be taken to protect the privacy of research subjects and the confidentiality of their personal
information.
Informed Consent
25. Participation by individuals capable of giving informed consent as subjects in medical research must be voluntary.
Although it may be appropriate to consult family members or community leaders, no individual capable of giving
informed consent may be enrolled in a research study unless he or she freely agrees.
26. In medical research involving human subjects capable of giving informed consent, each potential subject must be
adequately informed of the aims, methods, sources of funding, any possible conflicts of interest, institutional affiliations
of the researcher, the anticipated benefits and potential risks of the study and the discomfort it may entail, post-study
provisions and any other relevant aspects of the study. The potential subject must be informed of the right to refuse to
participate in the study or to withdraw consent to participate at any time without reprisal. Special attention should be
given to the specific information needs of individual potential subjects as well as to the methods used to deliver the
information. After ensuring that the potential subject has understood the information, the physician or another
appropriately qualified individual must then seek the potential subject’s freely-given informed consent, preferably in
writing. If the consent cannot be expressed in writing, the nonwritten consent must be formally documented and
witnessed. All medical research subjects should be given the option of being informed about the general outcome and
results of the study.
27. When seeking informed consent for participation in a research study the physician must be particularly cautious if the
potential subject is in a dependent relationship with the physician or may consent under duress. In such situations the
informed consent must be sought by an appropriately qualified individual who is completely independent of this
relationship.
28. For a potential research subject who is incapable of giving informed consent, the physician must seek informed
consent from the legally authorised representative. These individuals must not be included in a research study that has no
likelihood of benefit for them unless it is intended to promote the health of the group represented by the potential subject,
the research cannot instead be performed with persons capable of providing informed consent, and the research entails
only minimal risk and minimal burden.
29. When a potential research subject who is deemed incapable of giving informed consent is able to give assent to
decisions about participation in research, the physician must seek that assent in addition to the consent of the legally
authorised representative. The potential subject’s dissent should be respected.
30. Research involving subjects who are physically or mentally incapable of giving consent, for example, unconscious
patients, may be done only if the physical or mental condition that prevents giving informed consent is a necessary
characteristic of the research group. In such circumstances the physician must seek informed consent from the legally
authorised representative. If no such representative is available and if the research cannot be delayed, the study may
proceed without informed consent provided that the specific reasons for involving subjects with a condition that renders
them unable to give informed consent have been stated in the research protocol and the study has been approved by a
research ethics committee. Consent to remain in the research must be obtained as soon as possible from the subject or a
legally authorised representative.
31. The physician must fully inform the patient which aspects of their care are related to the research. The refusal of a
patient to participate in a study or the patient’s decision to withdraw from the study must never adversely affect the
patient-physician relationship.
32. For medical research using identifiable human material or data, such as research on material or data contained in
biobanks or similar repositories, physicians must seek informed consent for its collection, storage and/or reuse. There may
be exceptional situations where consent would be impossible or impracticable to obtain for such research. In such
situations the research may be done only after consideration and approval of a research ethics committee.
Use of Placebo
33. The benefits, risks, burdens and effectiveness of a new intervention must be tested against those of the best proven
intervention(s), except in the following circumstances:

Where no proven intervention exists, the use of placebo, or no intervention, is acceptable; or
Where for compelling and scientifically sound methodological reasons the use of any intervention less effective than the
best proven one, the use of placebo, or no intervention is necessary to determine the efficacy or safety of an intervention
and the patients who receive any intervention less effective than the best proven one, placebo, or no intervention will not
be subject to additional risks of serious or irreversible harm as a result of not receiving the best proven intervention.
Extreme care must be taken to avoid abuse of this option.
Post-Trial Provisions
34. In advance of a clinical trial, sponsors, researchers and host country governments should make provisions for post-trial
access for all participants who still need an intervention identified as beneficial in the trial. This information must also be
disclosed to participants during the informed consent process.
Research Registration and Publication and Dissemination of Results
35. Every research study involving human subjects must be registered in a publicly accessible database before recruitment
of the first subject.
36. Researchers, authors, sponsors, editors and publishers all have ethical obligations with regard to the publication and
dissemination of the results of research. Researchers have a duty to make publicly available the results of their research on
human subjects and are accountable for the completeness and accuracy of their reports. All parties should adhere to
accepted guidelines for ethical reporting. Negative and inconclusive as well as positive results must be published or
otherwise made publicly available. Sources of funding, institutional affiliations and conflicts of interest must be declared
in the publication. Reports of research not in accordance with the principles of this Declaration should not be accepted for
publication.
Unproven Interventions in Clinical Practice
37. In the treatment of an individual patient, where proven interventions do not exist or other known interventions have
been ineffective, the physician, after seeking expert advice, with informed consent from the patient or a legally authorised
representative, may use an unproven intervention if in the physician's judgement it offers hope of saving life, reestablishing health or alleviating suffering. This intervention should subsequently be made the object of research,
designed to evaluate its safety and efficacy. In all cases, new information must be recorded and, where appropriate, made
publicly available.
World Medical Association (WMA) Statement on Animal Use in Biomedical Research
http://www.wma.net/en/30publications/10policies/a18/
Adopted by the 41st World Medical Assembly, Hong Kong, September 1989
and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
Preamble
1. Biomedical research is essential to the health and well-being of our society. Advances in biomedical research have
dramatically improved the quality and prolonged the duration of life throughout the world. However, the ability of the
scientific community to continue its efforts to improve personal and public health is being threatened by a movement
to eliminate the use of animals in biomedical research. This movement is spearheaded by groups of radical animal
rights activists whose views are considered to be far outside mainstream public attitudes and whose tactics range from
sophisticated lobbying, fund-raising, propaganda and misinformation campaigns to violent attacks on biomedical
research facilities and individual scientists. These violent attacks are carried out by a relatively small number of
activists compared with those who use peaceful means of protest, but they have profound and wide-ranging effects.
2. The magnitude of violent animal rights activities is staggering, and these activities take place in many different parts
of the world. Various animal rights groups have claimed responsibility for the bombing of cars, institutions, stores,
and the private homes of researchers.
3. Animal rights violence has had a chilling effect on the scientific community internationally. Scientists, research
organizations, and universities have been intimidated into altering or even terminating important research efforts that

depend on the use of animals. Laboratories have been forced to divert thousands of research dollars for the purchase
of sophisticated security equipment. Young people who might otherwise pursue a career in biomedical research are
turning their sights to alternative professions.
4. Despite the efforts of many groups striving to protect biomedical research from radical animal activism, the response
to the animal rights movement has been fragmented, under-funded, and primarily defensive. Many groups within the
biomedical community are hesitant to take a public stand about animal activism because of fear of reprisal. As a
result, the research establishment has been backed into a defensive posture. Its motivations are questioned, and the
need for using animals in research is repeatedly challenged.
5. While properly designed and executed research involving animals is necessary to enhance the medical care of all
persons, we recognize also that humane treatment of research animals must be ensured. Appropriate training for all
research personnel should be prescribed and adequate veterinary care should be available. Experiments must comply
with any rules or regulations promulgated to govern humane handling, housing, care, treatment and transportation of
animals.
6. International medical and scientific organizations must develop a stronger and more cohesive campaign to counter the
growing threat to public health posed by animal activists. Leadership and coordination must be provided. In addition,
there must be a clear understanding of the rights of animals who are part of medical research, and the obligations of
those who undertake it.
The World Medical Association therefore affirms the following principles:
1. Animal use in biomedical research is essential for continued medical progress.
2. The WMA Declaration of Helsinki requires that biomedical research involving human subjects should be based,
where appropriate, on animal experimentation, but also requires that the welfare of animals used for research be
respected.
3. Humane treatment of animals used in biomedical research is essential and research facilities should be required to
comply with all guiding principles for humane treatment. Education about these principles should be provided to all
researchers in training.
4. Animals should only be used in biomedical research when it is clear that their use is required to achieve an important
outcome, and where no other feasible method is available.
5. Duplication of animal experiments should not occur unless scientifically justified.
6. The use of animals for the futile testing of cosmetic products and their ingredients, alcohol and tobacco should not be
supported.
7. Although rights to free speech should not be compromised, the anarchistic element among animal right activists
should be condemned.
8. The use of threats, intimidation, violence, and personal harassment of scientists and their families should be
condemned internationally.
9. A maximum coordinated effort from international law enforcement agencies should be sought to protect researchers
and research facilities from activities of a terrorist nature.