Devolved Research for Health in Priority Areas (DReHPA) Application Form

A.  Personal details

Important Notice 1)  Please read this form carefully before completing it. Consult the CNHR website (www. cnhrkenya. org) for further information on this Call. 2)  Ensure all sections are fully completed. Incomplete applications will be disqualified. 3)  All sections are critical for the selection of applicants 4)  Applications must be submitted electronically in PDF format and three hard bound copies to reach CNHR offices by close of business on August 8th 2016. Applications received after this date will not be considered. 5)  This application form should be submitted together with the proposal. 6)  All applications will be acknowledged. Double applications will be disqualified. 7)  Verification of the facts stated will be carried out. 8)  Incorrect information submitted will result in disqualification before, during or even after award of the DreHPA grant. 9)  Only Kenyan citizens, recent PhD graduates (less than five years) are eligible. Application No: _______________ (To be completed by CNHR) Devolved Research For Health in Priority Areas (DReHPA) Application Form

Date of Application:
How did you hear about this Grant:

1.  Last Name:

First Name:

2.  Address:

3.  Postcode:

4.  Home Telephone No.

Daytime Contact No.

5.  E-mail address:

6.  National Identification Number. (Attach a copy of your ID)

7.  What is your gender? MaleЁ FemaleЁ

B.  DReHPA Grant Conditionality’s

1.  Do you hold a Doctor of Philosophy (PhD) Degree Yes Ё No Ё

2.  If yes, which year did you graduate ____________

3.  What is the title of your DReHPA grant research proposal?_________________________________________________

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4.  In which county in Kenya will this Research work be carried out? _____________________________ (Please attach a letter of support from the County Executive of Health

5.  In which region in the county from the listed regions will your research be conducted?(North Eastern, Upper Eastern, Lower Eastern, Nyanza, Western, North Rift, South Rift, Nairobi, Central and Coast region).

____________________________________________________________________________________________________________________________________________________________________________________________________

C.  Education/Qualifications: (Begin with the most recent).

Please describe your research career to date, including any projects undertaken as part of a degree, or as part of your previous work. Mention any prizes, distinctions or special achievements at undergraduate or post graduate level.

College/University	Study Dates	Qualification and Grade	Date Obtained
Primary and High School Education	Study Dates	Qualification and Grade	Date Obtained
Ongoing Professional Development	Study Dates	Qualification and Grade	Date Obtained

D.  Training and Development Please use the space below to give details of any training or non-qualification based development which is relevant to the DreHPA Fellowship and supports your application.

Training Course	Course Details (including length of course/nature of training)

E.  Institution of Affiliation

Are you currently employed? ____________________ Yes Ё No Ё

If yes, answer please complete this section

Current employer: Please name the institution where you are currently employed/based.

Name of Employer/Institution:

Address:
	Postcode:

Your Position at the Institution:

Date Started:

F.  Institution of Affiliation where research funds will be managed (If different from above)

Name of Institution:

Address:
Postcode:
State the year this Organization was founded

Your Position at the Institution:

G.  Please give full citations including all authors, the title of papers and journals in which your work was published.

(You may add more space as you may require)

H.  Please list any grants or fellowships you have previously held. Please state the name of the awarding body, title of the project, amounts awarded and start and end dates of support. (You may add more space as you may require)

Name of Awarding body

Title of the project

Amounts awarded

Start dates

End dates

I.  How will this DReHPA fellowship help you in your career? Please describe why you wish to undertake this fellowship and how this will help your career (Maximum 500 words).

J.  Do you expect to have any other source of funding available that would contribute to this research? If yes, Please give details of the funder, the dates when the funding is available, the amount and what it covers.

K.  References

Please give the names and addresses of two referees.

Reference 1 Reference 2

Name: Job Title: Organisation: Address: Contact No: Email: How is this person known to you: Do you wish to be consulted before this referee is approached: Yes No

Name: Job Title: Organisation: Address: Contact No: Email: How is this person known to you: Do you wish to be consulted before this referee is approached: Yes No

L.  Declaration

Statement to be Signed by the Applicant (Candidates selected for interview will be notified three weeks after the closing date.) Please complete the following declaration and sign it in the appropriate place below. If this declaration is not completed and signed, your application will not be considered: I agree that CNHR Kenya can create and maintain computer and paper records of my personal data and that this will be processed and used for purposes of this grant. I confirm that all the information given by me on this form is correct and accurate and I understand that if any of the information I have provided is later found to be false or misleading, any offer of the grant may be withdrawn or terminated.

Signed:		Date:
(Only one copy of completed PDF forms of this application should be emailed to *****@***org and copied to *****@***org. Three hard bound copies should be emailed to The Director, Consortium for National Health Research (CNHR), Watermark Business Park, Karen, On Ndege road, Off Langata – Karen road, P. O. Box 29832-00202 KNH, Nairobi, Kenya).