Dr.
Dra.
Sr.
Sra.
Otra
First name:
* must provide value
Last name, family name, or surname:
* must provide value
Preferred name with credentials
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(eg, Jose Manuel Silva, MD, PhD)
Other names under which you have published:
(lastname, firstname middlename;
example: Silva, Jose Manuel)
Do you have an eRA Commons username?
* must provide value
Yes
No
Do you have an ORCID ID?
* must provide value
Yes
No
(Format:
####-####-####-###X or ####-####-####-####)
Home street address (1):
* must provide value
City:
* must provide value
Department:
* must provide value
Amazonas Ancash Apurimac Arequipa Ayacucho Cajamarca Callao Cusco Huancavelica Huanuco Ica Junin La Libertad Lambayeque Lima Loreto Madre De Dios Moquegua Pasco Piura Puno San Martin Tacna Tumbes Ucayali Other (specify)
Specify other department:
Country:
* must provide value
Peru
Other (specify)
Mobile phone:
* must provide value
Institutional email address:
* must provide value
Preferred email for D43 correspondence:
* must provide value
Institution
Personal
What is your gender?
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Male
Female
Prefer not to answer
Other
Citizenship:
* must provide value
Peru
Other (specify)
Specify other citizenship:
What ethnicity do you consider yourself to be?
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(Check all that apply)
Do you have a disability?
Yes
No
Which disability do you have?
(Check all that apply)
Specify other disability:
If special accommodations are required, please specify:
What best describes your career stage?
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Applying for a master's degree program for 2022
Currently enrolled in a master's degree program in 2022
Completed master's degree training, interesting in further research training
Applying for a doctoral degree program for 2022
Currently enrolled in a doctoral degree program in 2022
Completed doctoral degree training, interesting in further post-doctoral training
Current post-doctoral trainee
Junior faculty member interested in further research training
Other (specify)
Specify other career stage:
Are you currently enrolled at, or affiliated with, an any of these academic, research, or public health institutions
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(Check all that apply)
Specify other institution:
Have you ever been supported on a research grant?
* must provide value
Yes
No
Specify funding entity and type of grant:
Have you ever been a Principal Investigator (PI) on an NIH-funded grant?
* must provide value
Yes
No
Grant # for NIH-funded grant:
PRIMARY institution:
* must provide value
PRIMARY department / division:
* must provide value
What is your role at your PRIMARY institution?
* must provide value
(Check all that apply)
Institution street address (1):
* must provide value
Institution street address (2):
Institution City:
* must provide value
Department:
* must provide value
Amazonas Ancash Apurimac Arequipa Ayacucho Cajamarca Callao Cusco Huancavelica Huanuco Ica Junin La Libertad Lambayeque Lima Loreto Madre De Dios Moquegua Pasco Piura Puno San Martin Tacna Tumbes Ucayali Other (specify)
Specify other department:
Peru
Other (specify)
Do you have prior research experience?
* must provide value
Yes
No
Field of Research Experience:
* must provide value
(Check all that apply)
Specify other research field:
How many months of research experience:
Dedication to research (eg, full-time, part-time):
Part-time Full-time Other (specify)
Specify other time committment:
Cardiovascular Research Topics of Interest:
* must provide value
(Check all that apply)
Specify other research topic:
Are you currently enrolled in university degree training program?
* must provide value
Yes
No
At what univeristy are you currently enrolled?
* must provide value
Universidad Peruana Cayetano Heredia
Universidad Nacional del Altiplano
Other (specify)
Specify other university:
Bachelor's Degree
Master's Degree
Medical (eg, MD, etc.)
Non-medical Doctorate (eg, PhD, ScD, etc.)
Other (specify)
Specify other degree program enrolled:
January February March April May June July August September October November December Unknown
(Format: YYYY)
What degrees do you already hold?
* must provide value
(Check all that apply)
Specify other degrees held:
Specify institution for bachelor's degree training:
Universidad Peruana Cayetano Heredia
Universidad Nacional del Altiplano
Other (specify)
Specify other institution:
Month bachelor's degree earned:
January February March April May June July August September October November December Unknown
Year bachelor's degree earned:
(Format: YYYY)
Specify bachelor's degree field of study:
Specify institution for master's degree training:
Universidad Peruana Cayetano Heredia
Universidad Nacional del Altiplano
Other (specify)
Specify other institution:
Month master's degree earned:
January February March April May June July August September October November December Unknown
Year master's degree earned:
(Format: YYYY)
Specify master's degree field of study:
Specify institution for medical degree training:
Universidad Peruana Cayetano Heredia
Universidad Nacional del Altiplano
Other (specify)
Specify other institution:
Month medical degree earned:
January February March April May June July August September October November December Unknown
Year medical degree earned:
(Format: YYYY)
Specify field of medical training (eg, internal medicine, cardiology, obstretics):
Specify institution for doctorate degree training:
Universidad Peruana Cayetano Heredia
Universidad Nacional del Altiplano
Other (specify)
Specify other institution:
Month doctorate degree earned:
January February March April May June July August September October November December Unknown
Year doctorate degree earned:
(Format: YYYY)
Specify doctorate degree field of study:
Specify institution for ______ degree training:
Universidad Peruana Cayetano Heredia
Universidad Nacional del Altiplano
Other (specify)
Specify other institution:
Month ______ degree earned:
January February March April May June July August September October November December Unknown
Year ______ degree earned:
(Format: YYYY)
Specify ______ degree field of study:
Please tell us how you learned about the D43 Research Training Program in Chronic Non-communicable CVDs and Comorbidities in Peru?
(Check all that apply)
Specify other referral source:
Provide the name(s) of the individual(s) who told you about the program?
(lastname, firstname middlename; example: Silva, Jose Manuel)
Provide the institutional affiliation(s) of the individual(s) who told you about the program?
From which website did you learn about the program (provide exact website if possible)?
(Check all that apply)
Specify other website (provide exact website address if possible)?
From which meeting did you learn about the program (provide meeting name, organization, date, and location)?
From which social media source(s) did you learn about the program?
(Check all that apply)
Specify other social media source:
NOTE: The following links are used to upload requested documents.
Please name files as shown below:
Last name_First Initial_file name_yyyy-mmm-dd
Example:
Jose Silva would label his files as:
Silva_J_CV_2022-JAN-10
Silva_J_Biosk_2022-JAN-10
Silva_J_Train_2022-JAN-10
Silva_J_ResExp_2022-JAN-10
Silva_J_Int_2022-JAN-10
Click Upload file at right to attach your resume or curriculum vitae
* must provide value
Name files as shown below:
Last name_First Initial_CV_yyyy-mmm-dd (eg, Silva_J_CV_2022-JAN-10)
Click Upload file at right to attach your NIH biosketch (if available)
Name files as shown below:
Last name_First Initial_Biosk_yyyy-mmm-dd (eg, Silva_J_Biosk_2022-JAN-10)
Click Upload file at right to attach a summary of your RESEARCH TRAINING (program cousework) in the following areas (1/2 page max):
1) Biological sciences
2) Cardiovascular disease and comorbidities;
3) Epidemiology;
4) Biostatistics (use of statistical software packages);
5) Data management (eg, REDCap)
* must provide value
Name files as shown below:
Last name_First Initial_Train_yyyy-mmm-dd (eg, Silva_J_Train_2022-JAN-10)
Click Upload file at right to attach a summary of your RESEARCH EXPERIENCE in the area of cardiovascular disease, comobidities, and risk factors (1/2 page max):
* must provide value
Name files as shown below:
Last name_First Initial_ResExp_yyyy-mmm-dd (eg, Silva_J_ResExp_2022-JAN-10)
Click Upload file at right to attach a summary of your RESEARCH INTERESTS in the area of cardiovascular disease, comobidities, and risk factors (1/2 page max):
* must provide value
Name files as shown below:
Last name_First Initial_Int_yyyy-mmm-dd (eg, Silva_J_Int_2022-JAN-10)
One letter of recommendation is required to complete your application. This letter can be from your current (or past) Program Director, a mentor, or a colleague.
Please provide the information requested below.
Two letters of recommendation are required to complete your application. One from your current (or past) Program Director. Current program directors should guarantee your full participation in the D43 training program.
A second letter of recommendation may be from a mentor or colleague.
Please provide the information requested below.
Name:
* must provide value
Title:
* must provide value
Institution:
* must provide value
Phone:
* must provide value
Email:
* must provide value
Click Upload file at right to attach the LETTER OF SUPPORT #1.
* must provide value
Name files as shown below:
Last name_First Initial_LOS1_yyyy-mmm-dd (eg, Silva_J_LOS1_2022-JAN-10)
Name:
* must provide value
Title:
* must provide value
Institution:
* must provide value
Phone:
* must provide value
Email:
* must provide value
Click Upload file at right to attach the LETTER OF SUPPORT #2. Note: Unless directed otherwise by D43 program directors, a second letter of support is only required for PhD, postdoctoral, and junior faculty.
* must provide value
Name files as shown below:
Last name_First Initial_LOS2_yyyy-mmm-dd (eg, Silva_J_LOS2_2022-JAN-10)
Use the checklist at right to ensure that you have completed all items required for your app.
Please note that your app cannot be considered complete until your documents listed above have been uploaded and your letters of support/recommendation have been received.
* must provide value
Additional questions or comments:
Date Application Completed
* must provide value
Today Y-M-D
When you are ready, click the Submit button below to send us your application.
PDF of Completed Application
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