IARC Summer School in Cancer Epidemiology Application form

Transcription

1 IARC Summer School in Cancer Epidemiology Application form Instructions: Please complete electronically in English. Answer each question. All relevant information should be included on this form. Please make sure that the support letter is completed and signed by your supervisor prior to completing the form (see template linked to form). Applications without a support letter will not be considered. Once your application submitted, you should receive an acknowledgement . Should you encounter any problem to fill and/or submit the form, please contact the IARC Courses Programme, at [email protected]. Deadline for receipt of applications: 12 January LIST OF FIELDS TO BE COMPLETED: Identification: Please enter your name as it appears on your passport Family name/nom de famille/apellido* First name (Given name)/prénom/nombre de pila* WORK ADDRESS (institution) Institution Street City* State/Province ZIP/Postal code Country* Select country from dropdown menu

2 If you cannot find your country, select "Other" in the list above and enter your country * Telephone* Fax PRIVATE ADDRESS Communications will be sent to your WORK ADDRESS (documents, certificates,etc.) If you want it to be sent to another address (private address), please provide it below (steet, number, city, state/province, zipcode/postal code, country) Please indicate if you would like communications to be sent to your work or private address.* ( ) Work address ( ) Private address Gender* ( ) Female ( ) Male Age (number only)* Country of origin (nationality)* Select country from dropdown menu If you cannot find your country, select "Other" in the list above and enter your country Have you ever attended any previous courses organized by IARC?* ( ) No ( ) Yes. Please give details: How did you hear about the IARC Summer School? (Multiple answers possible)* [ ] Internet search (i.e. google) [ ] IARC website [ ] GICR website [ ] IARC staff [ ] A colleague who attended the course [ ] Your supervisor who attended the course [ ] A colleague who read/heard about the course

3 [ ] Your supervisor who read/heard about the course [ ] At an IARC meeting/workshop [ ] At another meeting/workshop [ ] Through a newsletter by [ ] Other. Please specify: Education and current position Education What were your basic studies?* ( ) Medicine ( ) Natural Sciences / Biology ( ) Epidemiology / Public Health ( ) Social Sciences ( ) Mathematics / Statistics / Computer Sciences ( ) Other: Provide the detail of your education background. Start with most recent. Exclude secondary school if you have a university degree or equivalent. Organise by: Name and city / From (year) To (year) / Field of study / Degrees* Current position In what type of institute are you working/studying?* [ ] Cancer research institute [ ] University department [ ] School of Public Health [ ] Ministry of Health [ ] Other Ministry [ ] Social insurance system [ ] Other. Please specify:

4 Which is your current scientific discipline?* [ ] Cancer registration data collection [ ] Cancer registration data entry [ ] Cancer registration reporting [ ] Epidemiology & Biostatistics [ ] Molecular Genetics [ ] Mechanisms of Carcinogenesis [ ] Molecular Pathology [ ] Infection & Cancer [ ] Molecular Cell Biology [ ] Other. Please specify: Title of your post* From (month and year)* Years of service (number only)* What are your work activities (by time)? Note: you have to answer for each type of activity, including "Other". If not relevant, please choose 0 % Percentages of time (%) Research Data management (i.e. cancer registrars) Patient care Teaching Administration Other Motivation to attend the course

5 Indicate which module(s) you wish to attend NB: You can select the following options: Module 1 only; Modules 1-2; Module 2 only. Please note that Module 2 has to be taken in its entirety (two weeks)". [ ] Survival Methods for Cancer Registries (15 to 19 June 2015) (one week) [ ] Introduction to Cancer Epidemiology (22 June-3 July 2015) (two weeks) Research experience and current activities, describing briefly your specific role (for the most relevant activities/projects)* What is your motivation for applying for this course? What do you hope to learn from it? Upon returning to your home country, in what ways would you implement what you learn? For Module 1: This module will target cancer registry staff from institutions with good quality incidence data who wish to develop cancer survival statistics at their registry. For Module 2: If you are currently (or plan to be) involved in analytical cancer epidemiology projects, please provide details.* Publications, if relevant (provide separate list if necessary - see below) If needed, upload the completed list of publications here Level of English How would you rate your English? Please give an honest assessment as we will be conducting random telephone interviews to test your English* ( ) Limited comprehension and conversation. ( ) Good comprehension, reading of newspapers, routine correspondence. ( ) Engage freely in discussions, read and write more difficult material. ( ) Understand, speak, read and write fluently. How often do you use the following software?* Every day Several times a month Rarely Never MS Excel (or equivalent) MS Word (or equivalent)

6 MS Power Point (or equivalent) Internet browser What is your level of biostatistics?* ( ) You have a good theoretical understanding of statistics and use R for at least some of your calculations or programming ( ) You regularly use Stata, SAS or similar statistical programs ( ) You use a spreadsheet to do some statistical calculations and/or occasionally use a specialised statistical program ( ) You understand some basic statistical concepts but do not calculate anything more complicated than means and sums ( ) You have no knowledge of statistics ADDITIONAL INFORMATION Course registration fees: There is one universal fee of 400 for this course, regardless of how many modules are taken. Participants based in low-, lower-middle and upper-middle income countries as listed by the World Bank are exempt from this fee. Finance: Living expenses in Lyon (hotel, meals and transport) as arranged by IARC require approximately 660 euros per week. Please indicate below if you need a financial contribution for your participation.* Own funds Contribution requested Travel ( ) ( ) Living expenses Registration fee ( ) ( ) ( ) ( ) Please upload the applicant's Director support letter*

7 I understand that, if I am accepted, I shall participate for the complete duration of the selected module(s).* ( ) Yes ( ) No Application date (MM/DD/YYYY)*