FACULTY NOMINATION OF TRAINEE FORM
Please complete this form to INITIATE training for the individual you are nominating to be a Hopkins Fogarty AITRP trainee. Email the completed form directly to Molly McHugh, Sr. Program Coordinator. Molly will contact the nominated trainee directly to
arrange all program matters. Additionally, Molly will consult with Denise Carolan, Fogarty Program Administrator, to verify
funding for the proposed training activity and with Eileen Painter, Financial Coordinator, who will arrange all financial matters
related to this training activity. (See page 2 for list of programs, types of training and B1/J1 visa information.)
1
Nominating Faculty
2
AITRP Program*
3
Trainee Name
4
Dept.
Telephone
FAMILY
Given
Middle
Trainee E-mail
5
Type of Training**
6
Dates of Training***
7
Name
Work
Personal
Start Date (mm/dd/yy)
End Date (mm/dd/yy)
US – city/state
International – city/country
Location of Training
Name of Institution
8
Specific Training Site
Address of Institution
City
9
Trainee Affiliation
10
Brief Description of
Training
[Please include
specifics of training
activities (ex. Lab
techniques to be
learned.)
names/affiliation of key
training mentors; if
multiple training sites
This information is
needed for reporting to
NIH/FIC.)
State
Name of Institution
Country
Abstract: Provide working title; indicate if trainee is 1st author
11
Anticipated Research
Outcomes
Publication: Provide working title; indicate if trainee is 1st author
NIH/Other Grant: Provide working title; indicate if trainee PI or Co-PI
12
Additional
Comments
*AITRP Program
o Core: Dominican Republic, Ethiopia, India, Malawi, Thailand, Uganda-Kampala, Uganda-Rakai
o Cross Cutting: Ethics, Substance Abuse, Tuberculosis, Vaccine Trials
o Blood Safety: China, India, Laos
o HAM: India, Thailand
o HPTN: China, India, Malawi, Thailand, Uganda-Kampala
o HVTN: China, India, Malawi, S. Africa, Thailand
o NIDA: Research in Drug Use
o China: Cohort Development
o BTEP: Georgia, Russia
o PSI: Uganda-Academic Alliance
o Cameroon – Vaccinology
o Substance Use and South and Southeast Asia
o Geographic Expansion: Moscow, Russia
**Type of Training
o Degree: MHS/ScM; MPH; Internet MPH; PhD/DrPH
o Post Doc: Short Term Mentoring or Long-Term Research
o US Short Course: Fogarty Summer Program; Summer Vaccine Trials Institute; Special Student Limited;
Special Student Regular, Internet
o Mentored: (Topics include: Advanced Lab, Clinical Observation, Database Analysis, Database
Management, Behavioral Sciences, Ethnography, etc.)
o Conference Support w/Abstract
o Conference Support w/o Abstract
o Network Meeting: HPTN, HVTN, ACTG
o Research: New & Minority Investigator: Research or Post Doc
o Research: Doctoral Dissertation Research
o Other: please describe
*** Visa Issues
B1 or B2 (Visitor/Business) Visa – if trainee is supported by Hopkins AITRP 9 days or fewer
J 1 (Exchange Visitor) Visa – if trainee is supported by Hopkins AITRP more than 9 days
[DS-2019 document required – formerly known as IAP-66]
Note: 90 day lead time needed to request J-1 visa document (DS2019) from JHMI International Services. It
is also taking longer for individuals to get appointments at US Consulates.
C:\Fogarty Data\AAAAA\AAADenise\FAITRPmasters\MASTER.facultynomination.pdfversion.form.doc; 10/30/03