Novo Nordisk Access to Insight Grants & Awards Programme
Scholarship
The Access to Insight Training Scholarship is designed to cover a period of minimum 6 months to up to 12 months of
training and requires a minimum experience level of the applicants (2–4 years in haematology and at least 1 year in
haemostasis/haemophilia). This application form must be completed in full for you to be considered for the Novo Nordisk
Access to Insight Grants & Awards Programme. An application will be considered for review by the Core Faculty members
only if it is submitted with the requested documents, i.e. cover letter, curriculum vitae, and training description. The
one-page cover letter should include a description of why you are applying for the scholarship and should state your
commitment to pursuing a career within haemostasis/haemophilia. Applicants are eligible to apply only if they have the
institution’s agreement to do so. Funding will be offered in relation to your training period and will be transferred to the
institution and not to the applicant.
1. Personal data
1.1 Name of applicant
Title
First name
Middle name
Last name
1.2 Date of birth
1.3 Qualifications
2. Applicant‘s institution
2.1 Institution/organisation
2.2 Institution address
Street
City
State
Postal code
Country
2.3 Phone (country code, area code, extension)
2.4 Fax
2.5 Email
Date obtained
3. Official approval by applicant´s institution/organisation
3.1 Name
3.2 Title
3.3 Address
Street
City
State
Postal code
Country
I hereby confirm that, if successful, the applicant may have leave of absence to attend the training.
Signature
Date
Applicant: I certify that the statements in this application are true, complete and accurate to the best of my
knowledge. I agree to accept responsibility for attending the training until the end of the designated time frame.
Applicant’s signature
Date
Supervisor of applicant: I certify that the statements in this application are true, complete and accurate to the
best of my knowledge.
Applicant‘s supervisor‘s signature
Date
Years of experience in haematology
Years of experience in haemostasis/haemophilia
Previous training (limit: 500 words)
Summarise any general and specialised medical training taken to date.
Duration of the training
Start date
6 months training application
End date
12 months training application
Training description (limit: 500 words)
Clinical training should be in the field of haemostasis and rare bleeding disorders. Please describe the clinical duties you
expect to perform during the scholarship what you are hoping to achieve from this training, what influence it would have
on your career goals, how you would use these achievements thereafter, and what skills could be applied at your home
institute after the training is completed? (You may wish to base your training description on the following article:
Astermark et al. Haemophilia 2008.)
Additional comments
My preferred Haemophilia Training Centres (HTCs)
Please list your top 2 HTCs and a contact person of the respective HTC where you would like to undertake the training.
I have a written confirmation from my 1st priority HTC to accept me as trainee for the described project,
if successful.
1st priority
Contact person in the respective HTC
Name
Street
City
State
Postal code
Country
Email address
Phone
Fax
2nd priority
Contact person in the respective HTC
Name
Street
City
State
Postal code
Country
Email address
Phone
Fax
Please consider possible political or other issues that might hinder you from travelling and staying in the
country of your suggested HTC for a longer period of time.
Please send the signed and completed form together with a cover letter and a curriculum vitae (max. 2 pages)
containing education, positions and publications as email attachments to [email protected] by the
submission deadline. Thank you!