| First Name |
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| Middle Initial |
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| Last Name |
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| Address Line 1 |
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| Address Line 2 |
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| City |
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| State |
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| Zip Code |
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| Country |
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| Home Phone |
- - |
| Work Phone |
- - |
| Cell Phone Number |
- - |
| Email Address |
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| Date of Birth (MM/DD/YY) |
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Do you consider yourself Hispanic or Latino?
Which of the following best describes you?
Do you currently meet requirements to receive NIH funding? (i.e., U.S. citizen, permanent resident, VISA)
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Education and employment
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Highest Degree (PhD, MD)
and Year Conferred |
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| Highest Degree Institution |
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| Discipline of Highest Degree |
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All Other Degrees
and Years Conferred |
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| Current Title/Position |
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| Institution |
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| Department |
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| Address 1 |
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| Address 2 |
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| City |
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| State |
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| Zip Code |
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research and Scholarship
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| Number of Peer-Reviewed Publications |
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| Number of First-Authored Peer-Reivewed Publications |
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| Number of Federally-Funded Grants Awarded (PI or Co-PI) |
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| Recommendations |
Name of First Recommender
(Home Institution) |
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First Recommender Role
(e.g., post-doctoral supervisor, department chair) |
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| First Recommender Institution |
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| First Recommender E-mail Address |
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| Name of Second Recommender |
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| Second Recommender Institution |
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| Second Recommender E-mail Address |
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additional materials
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An official transcript of highest degree earned will be forwarded from:
(Institution)
Transcripts should be e-mailed (ethicsinst@fordham.edu) or mailed to:
HIV Prevention Research Ethics Training Institute
441 East Fordham Road, Dealy 226
Bronx, NY 10458
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| Fellows will be matched with mentors based on similarity in interest and expertise. However, please feel free to identify any faculty member(s) you may be interested in working with on the mentored research project (not required) |
Below please include a 300-word description of your HIV research training, scholarship (i.e. publications, presentations, funding), and immediate and long-term research and career goals. If applicable, please indicate any drug use research populations with which you have experience
Below please include a 150-word statement describing your interest and relevant training or experience in HIV prevention research ethics.
Below please include a 150-word description of the topic in HIV prevention research ethics that you would like to explore in the mentored research project (for examples of empirical research ethics articles, please view the selected bibliography on www.hivpreventionresearchethics.org)
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Please describe the access you will have over the next 2 years to the HIV or HIV risk population you identified in your mentored research question. In your response please consider the sample size and geographic access that will be necessary to complete the project as described.
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Please describe your relevant training and experience in the type of qualitative and/or quantitative methods proposed for this study. This answer should also demonstrate your ability to independently design and implement a research project at standards suitable for peer review journals and potential NIH funding.
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PLEASE ATTACH MOST RECENT C.V. Attachments must be in .DOC, .DOCX or .PDF format.
* UPLOAD :
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