2015 Application Form GLOBAL HEALTH SCHOLAR EXCHANGE PROGRAMME:

Developing Global Solutions for Global Health Problems
GLOBAL HEALTH SCHOLAR EXCHANGE PROGRAMME:
2015 Application Form
Room 202B, JC School of Public Health and Primary Care, Prince of Wales Hospital, Shatin. HKSAR
Phone: 2252-8465 Fax: 2145-7489 Email: globalhealth@cuhk.edu.hk Website: www.cuhkcgh.org
This application form is designed for Public Health postgraduate students
from overseas institutions to do a research attachment at the Chinese
University of Hong Kong.
1) The closing date for 2015 Global Exchange Programme applications are as follows:
Potential
period
exchange
Application deadline
Spring Term
Summer Term
Autumn Term
January – June, 2015
June – July, 2015
September
December, 2015
7 November, 2014
27 March, 2015
29 May, 2015
–
(by 11.59pm, HK time)
2) Please complete ALL information in ALL sections of this application form. Incomplete
forms will not be accepted by the Centre.
3) Please provide your most updated Curriculum Vitae, and photocopy of postgraduate
academic reports, along with your application.
4) The completed application form and supporting documents should be submitted to the
Centre for Global Office via email or fax by the applicable deadline date.
5) Any personal data provided in this form is for internal use only. Information collected will
not be disclosed to any other party in a form that would identify you unless it is permitted
or authorised.
PERSONAL INFORMATION
English Name: _________________________________ Chinese Name: ______________________
(Surname)
(Given Names)
Date of Birth (dd/mm/yy): ________________________ Gender: F / M
Nationality (Passport): ___________________________ Hong Kong ID number: ______________( )
Correspondence Address: ___________________________________________________________
___________________________________________________________________________________
Contact: (Home) ___________________________
(Mobile) ______________________________
Email address: _______________________________________________________________________
Current Institution: ____________________________________________________________________
Graduate Program enrolled: _____________________________________________________________
Year of Study: _____________
Cumulative GPA: _______________
Emergency Contact
Name: __________________________________ Relationship: _________________________________
Tel: ____________________________________ Email: _______________________________________
LANGUAGES
Spoken languages (of at least conversational level)
 English  Cantonese  Mandarin  Others (Please specify): ____________________________
Reading language (of level at least needed to read a newspaper)
 English  Cantonese  Mandarin  Others (Please specify): ____________________________
Written language (of level at least needed to write an informal email)
 English  Cantonese  Mandarin  Others (Please specify): ____________________________
SKILLS (please tick as many as applicable and provide further information where appropriate)
 Qualitative skills ______________________________________________________________________
 Quantitative skills ____________________________________________________________________
 Epidemiological and statistical skills______________________________________________________
 Monitoring and evaluation ______________________________________________________________
 Surveillance design ___________________________________________________________________
 Clinical trials/lab experience ____________________________________________________________
 Excellent written communication skills ____________________________________________________
 Excellent interpersonal communication skills _______________________________________________
 Computer/software skills; e.g. __________________________________________________________
 Medical/first aid skills; e.g. _____________________________________________________________
 Others (please specify): _______________________________________________________________
______________________________________________________________________________________
AREAS OF INTEREST (Please tick as many as applicable)

Autism
 Disaster preparedness

Child/ teen health
 Epidemiology

Climate change
 Infectious Diseases

Bioethics
 Urbanisation and health

Health policy (HK & China)
 Migration and health

Others (Please specify): _________________________________________________
PROPOSED DATES FOR EXCHANGE
You can choose more than one:

Spring Semester (January – June 2015)

1 month

Summer Semester (June – July 2015)

2 months

Fall Semester (September – Dec 2015)

3 months
Please specify your preferred Exchange time period in exact dates:
_______________________________________________________________________________________
BACKGROUND (please write no more than 200 words for the following sections)
1. Tell us about yourself, your background and your interest in public health.
Signature: _______________________________
Date: ___________________________
- The End 2. Which areas of public health are you most interested in? Why?
3. What relevant skills and experience do you have to contribute to innovative research projects?
4. How will this Global Exchange experience benefit your long-term goals?