PERSONAL DATA (for AI use only)
ALBERTA INNOVATES
GRADUATE STUDENTSHIP PLUS OPTION APPLICATION FORM
1500, 10104 – 103 Avenue, EDMONTON, AB T5J 0H8
Phone: (780) 423-5727 Fax: (780) 429-3509 e-mail: [email protected]
PLEASE SUBMIT ONE HARD COPY OF THE ORIGINAL APPLICATION.
As a public body, the Alberta Innovates is regulated by the Freedom of Information and Protection of Privacy Act (FOIPP) of
Alberta. As such, the information on this Personal Data page will be for AIHS internal use ONLY and will not be communicated
to anyone outside of AIHS.
SECTION 1: PERSONAL DATA
Proposed PLUS Option Organization:
Applicant: Surname, First Name, Middle Initial(s)
Birthdate:
Year
Gender: (Check)
Month
Day
Male
Complete Mailing Address:
Female
Phone:
Fax:
E-mail:
Alberta Innovates (AI) supports Alberta research institutions in their efforts to promote and ensure the highest standards of research
and scholarship practice and behaviour. By his/her signature below, each applicant asserts that this application adheres to all policies,
procedures, and ethical standards in place at his/her sponsoring organization/institution, including those regarding integrity in research
and scholarship. AI reserves the right to confirm this assertion through independent means. AI wishes to alert applicants to the
consequences of misrepresentation in this application, including misrepresentations of authorship, credentials or research support. In
the event of material deviations of the information in this application from reference sources, including citation sources (in the case of
authorship), issuing organization(s) (in the case of credentials), or granting agencies (in the case of research support), AI reserves the
right to disqualify the applicant from the competition in question. Further AI actions may include disqualifying the applicant from future
AI competitions for a time period to be set at AI’s sole discretion, withdrawal of any remaining installments of support for any existing AI
grant or award for which misrepresentation appears in the submission, and seeking partial or full repayment of any past financial
support under any AI grant or award for which misrepresentation appears in the submission.
Further information on AI’s support for research and scholarship integrity is found in the Program Guide for the Graduate Studentship at
http://www.aihealthsolutions.ca/grants/training-and-early-career-development-programs/docs/trainee-award-program-guide.pdf.
At time of proposed start date of PLUS Option, will you have completed your Graduate Studentship award?
YES
NO
If NO, please complete Section 2: Acknowledgment of PLUS Option and Section 3: Signatures.
If YES, please complete only Section 3: Signatures.
ALBERTA INNOVATES
GRADUATE STUDENTSHIP PLUS OPTION APPLICATION FORM
1500, 10104 – 103 Avenue, EDMONTON, AB T5J 0H8
Phone: (780) 423-5727 e-mail: [email protected]
SECTION 2: ACKNOWLEDGEMENT OF PLUS OPTION. The undersigned agree to, and accept, that the applicant is applying to
undertake the PLUS Option and will not be actively involved in research pertaining to their graduate degree for the duration of the PLUS
Option. Not required if PLUS Option occurs after completion of AIHS Graduate Studentship Award.
Printed Name
Primary Research Supervisor:
Signature
Faculty/Dept.
Date
Co-Supervisor (if applicable):
Co-Mentor:
Career Advisor:
Primary Dept. Head/Chair:
Faculty Dean:
Research Services Office:
SECTION 3: SIGNATURES. The undersigned agree to, and accept, the general conditions governing any award made pursuant to the
sponsorship of this application, as set out in the AIHS Guidelines, located at www.aihealthsolutions.ca. The host organization agrees to
administer the PLUS Option award and will comply with all AIHS Terms and Conditions and award requirements. The PLUS Option
supervisor agrees to directly supervise the applicant for the duration of the PLUS Option award. The PLUS Option organization agrees
to host the applicant for the duration of the PLUS Option award and will provide the applicant with the required resources in order to
complete the proposed PLUS Option.
Printed Name
Applicant:
Signature
PLUS Option Supervisor:
Organization Administering Award/Research Services
Office:
Application - 2
Graduate Studentship PLUS 2017
Date
ALBERTA INNOVATES
GRADUATE STUDENTSHIP PLUS OPTION APPLICATION FORM
A. APPLICANT
Surname, First Name & Middle Initial(s)
B.
PLUS OPTION SUPERVISOR AND HOST ORGANIZATION
Proposed Supervisor for PLUS Option (Prefix, Name & Title)
Complete Mailing Address
Contact Numbers:
Phone:
Fax:
E-mail:
C.
GRADUATE PROGRAM
1. Anticipated completion date of graduate program:
2. Proposed start and end dates for PLUS Option:
D.
Completion Date: xx/xxxx
MM/YYYY
Start xx/xx/xxxx
End xx/xx/xxxx
MM/DD/YYYY
MM/DD/YYYY
APPLICATION REQUIREMENTS
Attach applicant’s up-to-date curriculum vitae
Cover Letter from proposed PLUS Option host organization that outlines the host organization’s commitment to
training, mentoring and supervision of the applicant. The letter could be from the proposed PLUS Option supervisor or
academic program coordinator verifying enrollment.
Letter of Intent from the Applicant. Describe the PLUS Option and outline how the activities being undertaken in the
PLUS Option are aligned with the applicant’s Career Development Plan.
Attach PLUS Option supervisor’s up-to-date biographical sketch. Not required if applicant enrolled in degree
program for PLUS Option.
Background information on the organization where the PLUS Option will take place and include an overview of its
key activities (1-page; 12-point font minimum)
PLUS Option Work Plan (maximum 2 pages; 12 point font minimum). Attach a work plan that:
Identifies the area of focus and outlines the training/educational activities that will be undertaken during the PLUS
Option.

Lists specific objectives and anticipated outcomes of participating in the PLUS Option.

Describes how the PLUS Option ties to your career plans and goals and how the PLUS Option links to the
applicant’s current graduate training program, career and professional development.

Describe how the PLUS Option will enrich your skills, professional development, and career opportunities.

Application - 3
Graduate Studentship PLUS 2017
ALBERTA INNOVATES
GRADUATE STUDENTSHIP PLUS OPTION APPLICATION FORM
E.
BIOGRAPHICAL SKETCH – PLUS OPTION SUPERVISOR
Provide the following information for the PLUS Option Supervisor. A maximum of four pages (excluding this information
cover page) may be used.
PLUS OPTION SUPERVISOR NAME
INSTITUTION/ORGANIZATION AND
POSITION TITLE
EDUCATION / TRAINING / RELEVANT WORK EXPERIENCE (List only academic training and/or work
experience relevant to the PLUS Option activities)
Degree
(if applicable)
Field of Study
Institution/Company/City/Country
Year
and/or
(if applicable)
Position
The attached biographical sketch information may not exceed a total of four pages (excluding this information
cover page). Please Note: Only the first four pages, along with this information cover page, will be included.
The following additional information is to be provided according to the following headings:
A. Personal Statement. Briefly describe why your experience and qualifications make you particularly well suited for
the training, mentoring and supervision of the applicant.
B. Contributions to your Field. List published or accepted publications only. Do not list those that are in
preparation or submitted. List only the most recent or relevant publications (last 5 years). Underline any authors
that were/are your trainees. Contributions may also include government reports, clinical practice guidelines,
patents, knowledge exchange activities, presentations, interviews or other publications (newspaper, magazine,
etc.), etc.
C. Financial Support for Research (if applicable). Include active and/or pending operating grants only. Do not list
equipment-related or research allowances associated with studentship or fellowship awards. Please specify if you
are the principal or co-investigator, and identify only the portion of the funding you receive.
D. Current trainees indicating the level of training and expected completion dates. For non-academic
sectors, please list current staff that you manage and give a short description of their roles.
E. Relevant honours, awards, recognitions related to research, mentoring and/or teaching.
Application - 4
Graduate Studentship PLUS 2017