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APPLICATION FORM

*****
International course in Epidemiology, Biostatistic
s&
Qualitative research methods (EBQ)
17 October - 25 November 2016
Last Name (as indicated on your passport)
First Name
Current Nationality
Nationality at Birth
Date of Birth (in day-month-year order)
Place of Birth (as indicated on your passpor
t)
Country of Birth (as indicated on your pass
port)
Gender
Civil Status
Minors (name and age)
Current Residence Address

Phone Number(s)
E-mail
o
o
o
Specify level of education

Bachelor
Master
Enrolled PhD student:
o University:
.
o PhD promoter(s):

Diploma + issue date

..

To apply for the EBQ Course 2016 kindly fill in this form, preferably digitally, or write legible (block l
etters). Kindly submit 1)
this application form, 2) a recent CV (max. 2 pages) and 3) a letter of support from your su
pervisor to
global.health.institute@uantwerp.be.
Starting the 2016 edition VLIR-UOS scholarships are available. To see whether you are eligible to
apply, kindly go to page 6.
Submission deadline is 1 May 2016.

Passport Number
Issue Date
Issued by (the authority that issued the pa
ssport
and
the place
of issue)
Expiration
Date
Name of the organisation (pu
blic EBQ 2016 Application Form
service,

educational

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instituti

on)

2. Current jo
b

Employers address
Supervisors name

Supervisors e-mail address


Provide information about your current educational and/or professional activities

3. PhD or research subject


Title:

1.Short
Personal
detai
description
(200 words):
ls

EBQ 2016 Application Form

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4. Relevance of the EBQ course to your research


Describe the relevance of the course 1) for your project or PhD research ; 2) for the institute with
which you are affiliated

5. Prior knowledge (Tick as appropriate; you are allowed to tick several options)

Quantitative study design


Data analysis / Biostatistics
Qualitative study design
Other: .

6. Software knowledge (Tick as appropriate; you are allowed to tick several options)

SPSS
R
STATA
SAS
ATLAS
NVIVO
Other: .

7. Data set

(Tick as appropriate; you are allowed to tick several options)

I do not have my own dataset available during the course


I have my own dataset available during the course
Qualitative research
Quantitative research

EBQ 2016 Application Form


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Provide a brief explanation of your available data set.

8. Personal motivation
Describe why it is important for you to attend this course.

How did you learn about this International Training Programme?

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9. Declarations by the Applicant


I, (name and surname), do hereby declare that
what is stated above is true to
the best of my knowledge & believe. In the event I receive a support grant, I declare to mention the VLIRUOS as (co-)sponsor of
the generated output, such as scientific articles, poster, interview, oral presentation.

Signature of applicant

Date and place

A scanned signature is allowed.

Kindly submit 1) this application form, 2) a recent CV (max. 2 pages) and 3) a letter of support fro
m your supervisor to
global.health.institute@uantwerp.be. Submission deadline is 1 May 2016..

10. Declarations by the Supervisor


To be completed by the person granting permission to the applicant to travel (i.e. employer, promoter,
professor, etc.).
I, (name and surname) hereby certify that applicant
.
(name and surname) is granted permission to attend the EBQ course from 17 October to 25 Novemb
er 2016.
Signature of supervisor

Date and place

A scanned signature is allowed.

Kindly send a letter of support to global.health.institute@uantwerp.be stating 1) the relevance of


the EBQ course for the
applicant and the organization (s)he works for, as well as 2) conformation that the applicant will ret
urn to his/her current
position within your organization after completion of the course.

EBQ 2016 Application Form

11. Funding options (Tick as appropriate)

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I do not to apply for a VLIR-UOS scholarship and will be

o
o
o

self-sufficient
supported by a VLIR-UOS project (TEAM or IUC):
receiving a support grant from

I wish to apply for a VLIR-UOS scholarship as I am qualified as indicated below.

VLIR-UOS scholarships
Please read carefully the eligibility criteria below to check whether you qualify for a VLIR-UOS Scholarship
application. Only if you
can tick all the boxes, you may continue to complete the form. If you have any questions related to these ei
ght criteria, kindly
contact global.health.institute@uantwerp.be.

I currently live in and have the nationality of one of the 54 countries from the country list (see below
). Note: You do not
need to have the same nationality and place of residence. However, applicants need to be a residen

t in one of those
countries at the time of application.
On 01 January 2016 I am not older than 45 years of age.
I am employed by an academic institution, research institute, public service, social economy or NGO.
This is the only VLIR-UOS scholarship I am applying for this year (2016).
I have never before received a VLIR-UOS scholarship to attend an International Training Programme
(like EBQ)
I am not in any way involved in a VLIR-UOS sponsored IUS or TEAM project, nor another DGD sponsor
ed project.

**************
54 VLIR-UOS scholarship countries
Africa: Benin, Burkina Faso, Burundi, DR Congo, Ethiopia, Gambia, Ghana, Guinea, Ivory Coast, Cameroon,
Kenya,
Madagascar, Malawi, Mali, Morocco, Mozambique, Nigeria, Rwanda, Senegal, Tanzania, Togo, Tunisia, Ugan
da, Zambia,
Zimbabwe, South Africa
Asia: Bangladesh, Cambodia, Philippines, India, Indonesia, Jordan, Laos, Nepal, Palestinian Territories, Sri L
anka, Thailand,
Vietnam
Latin America: Bolivia, Brazil, Colombia, Cuba, Dominican Republic, Ecuador, Guatemala, Guyana, Hondu
ras, Haiti, Mexico,
Nicaragua, Paraguay, Peru, Suriname, Uruguay
**************

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