Beruflich Dokumente
Kultur Dokumente
Scholarship Application
Name of
Institution:
Department:
E-mail:
Passport
Number:
Passport
Expiry date:
Sex: MALE FEMALE
Date of birth:
Place of birth:
Country of
citizenship
Telephone
number:
Current full
home address:
All personal information provided is treated as confidential and will be shared only with the
Scholarship selection committee and CRDF Global. Please note according to US grant regulations,
awards must not be made to parties listed on the government wide exclusions in the System for Award
Management (SAM). Therefore, this system will be checked before issuing an award. Only your name,
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city, country, and place of work will appear in this Training Academy’s final report. Number and
amount of scholarships will depend on funding.
YOUR WORK:
10. What types of consultation or teaching do you do with staff in your institution around psycho-
oncology issues?
_______________________________________________________________________________
___________________________________________________________________
11. Approximately how many students (medical/nursing/psychologist/social work) do you teach in one
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year? __20
12. How many psycho-oncologists are there at your hospital or institution in total? __5
13. What other disciplines (medicine, nursing, social work, psychology, psychiatry, occupational
therapists etc.) do you work with in providing psychosocial care?
____ Emotionally Focused Therapy (EFT)
15. If yes, are you on the Curriculum Committee at your university? YES NO
EDUCATION: Please list your educational experiences and degrees below starting with the most
recent:
Graduate
Education (list +Emotional
Master’s and Freedom
Ph.D. study on Technique (EFT
separate lines) tapping therapist)
16. If applicable, please list any extenuating circumstances (i.e., leave of absence from work for
maternity/paternity, sickness, etc.) that explain a delay of more than 6 years since completion of
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your training:
17. If you have taken any post-college courses in Psycho-Oncology or related courses relevant to your
work in Psycho-Oncology, please list below:
19. Have you in the past received a scholarship to attend an IPOS Academy? YES NO
20. What motivates you to attend this PsychoOncology Research Training Academy? (no more than
100 words)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________
21. How will you use this new research knowledge? (no more than 100 words)
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__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________
22. Please describe a research project you would be interested in developing (no more than 100
words):
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________
____________________________________________________________________________
23. Are you able to attend the entire 3 days Training Academy in Hong Kong (October 28-30)? YES
NO
24. Provided IPOS secures funds, are you able to attend the entire 3 days of the IPOS Congress in
25. Are you a member of the International Psycho-Oncology Society (IPOS)? YES NO
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____________________________________________________________________________________
__________________________________________
28. What elements of your research environment (research activity, resources and infrastructure
such as internet access, to databases, to scientific articles, to startup funds and mentorship) will
contribute to the quality of your future research training experience?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________
29. Barriers: describe what you anticipate will be the main barriers to developing and implementing
your research project in your current setting, and your plan to overcome these barriers. (no more
than 100 words)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________________________________
Note: Please note that travel arrangements and accommodations will be organized by IPOS for
recipients of the NCI Travel Scholarship. There will be no possibility of extending or altering these
plans.
Note: It is the responsibility of the applicant to ensure the application is complete. Incomplete
applications or handwritten applications will be automatically withdrawn from the contest without
notice. Applications will only be accepted if they are received at your earliest convenience before
June 22, 2018 to the following e-mail address: applications2018RTA@ipos-society.org. Applications
must include the fully completed Application Form, a five-page Curriculum Vitae for the applicant,
and a Copy of his/her Passport valid for travel to Hong Kong during the Academy.
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Note: Please send any questions you may have about this call for applications to the following e-
mail address: info2018RTA@ipos-society.org. IPOS will only be available to answer any questions
related to this call for applications from May 17, 2018 to June 7, 2018, after which IPOS will no
longer be able to answer. After June 7, 2018, the next correspondence the applicants will receive is
the result of the competition. Participants should anticipate receiving the results by the first week
of August. If you have not received a response, please check the IPOS website to know if there has
been a delay in the processing of the applications. If you have not received a letter of offer by the
first week of August, unless otherwise indicated on the IPOS website, it means that you were not
selected for the scholarship.
Please confirm by checking the boxes that you meet the eligibility criteria below, and sign at the
end of this page.
________________________________________________
Signature of applicant
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