Cycle 2 Program Application Form | African Cancer Stars

Key Dates

Contact Information

First Name

Middle Name

Surname

Title

Position

Institution, Department

Address

City, Postcode, Country

Contact phone

Training Track

English Language Proficiency

Training Certifications

Human Subjects Research

Good Clinical Practice

Responsible Conduct of Research

Conflicts of Interest

Bioethics

Conflict Management

Project Management Professional

Certified Associate in Project Management

STARS Training Institution

Are you Affiliated with a Partner Organization? (Y/N) (See list; https://www.africancancerstars.org/partners)

Name of Partner Organization

Organization Contact Name

Contact Email address

Is your institution included on the pre-approved training institutions list? (See list; https://www.africancancerstars.org/approved-institutions)

Mentor Team (Please enter information of 2 or 3 of your mentors)

Note: The mentor list is not required at this time. If you have existing mentors you plan to work with, please list them here. If you do not have mentors at the time of application, additional mentors will be identified upon selection into the program

Name	Organization	Email	Area of Expertise
Name (1)	Organization (1)	Email (1)	Area(s) of Expertise (1)
Name (2)	Organization (2)	Email (2)	Area(s) of Expertise (2)
Name (3)	Organization (3)	Email (3)	Area(s) of Expertise (3)

Education (Enter 4 recent, with the most recent first)

Institution and Location	Degree Awarded	Completion Year	Field of Study
Institution and Location 1	Degree Awarded 1	Completion year 1	Field of study 1
Institution and Location 2	Degree Awarded 2	Completion year 2	Field of study 2
Institution and Location 3	Degree Awarded 3	Completion year 3	Field of study 3
Institution and Location 4	Degree Awarded 4	Completion year 4	Field of study 4

Applicants Statements

APPLICANT’S BACKGROUND AND EXPERIENCE. Describe your professional and academic record, prior training, and experience to explain why you to seek this training (250-500 Words)

PROBLEM STATEMENT • For All Applicants: • Provide a statement and justification of the problems/needs that will be addressed by this training and what impact you can have to address these problems/needs • Explain the importance of a problem, need, or a critical barrier to progress that the proposed training addresses. • For PI Track Only: • Describe the strengths and weaknesses in the rigor of prior research (both published and unpublished) that justifies the need for the proposed training and research project. • Explain how the proposed training and research project will improve scientific knowledge, technical capability, and clinical practice in one or more broad cancer fields. (250-500 Words)

TRAINING PLAN. Please include ancillary coursework, meeting attendance, site visits or exchange, and project concept that will be undertaken during training (to be fully developed and refined during the training period). Also, include the following: • For all applicants: • Describe the features of the training program that will lead to a successful research career • Timeline of activities • For PI Track Only: Describe the concepts, methods, technologies, treatments, services, or preventative interventions proposed in your project and how they will lead to future career objectives. If the candidate is proposing to gain experience in a clinical trial as part of his or her research training, describe the relationship of the proposed research project to the clinical trial. Note that clinical trials themselves will not be supported through this mechanism. (250-500 Words)

Attach Biosketch

One file only. 256 MB limit. Allowed types: , pdf.

Institutional Support Letter

One file only. 256 MB limit. Allowed types: pdf, docx.

I certify that the Information provided is accurate to the best of my knowledge

Signature

Date