Introduction to Molecular Epidemiology.

* Last Name:
* First Name:
* Title:
* Organization:
* Citizenship
* Street Address (Please do not provide a PO. BOX)
* City
* State/Province
* Country
* Day Time Phone
* Fax
* Primary E-mail address:
* Secondary E-mail address:
* Institutional webpage

My organization is (check one)
( ) Government
( ) Educational
( ) Basic Research
( ) Private for profit
( ) ONG (nonprofit) 

Time in your organization:

Please check your latest degree. 

( ) PhD
( ) MD
( ) MSc
( ) Veterinarian
( ) Graduate Student
( ) BSc or “Licenciado”
( ) Technician without college degree 

Please check the categories that better describe your work (Maximum 2)

(  ) Lab technician
(  ) Researcher
(  ) Data analyst
(  ) Epidemiologists
(  ) Health provider
(  ) Health program planner/manager
(  ) Faculty

Field of Study (example “epidemiologists that works in Dengue”):

Describe how this workshop will benefit your professional development? (Maximum 300 words)

Describe how your professional development impacts your organization /institution? (Maximum 300 words)

Explain/Describe your experience using molecular methods? (Maximum 200 words) 
 
Do you have contacts/ collaborations with organizations in your country related with epidemiology and public health? Briefly describe the nature of such collaborations (Maximum 300 words)

Do you have contacts/ collaborations with organizations in your country related with basic research or universities? Briefly describe the nature of such collaborations (Maximum 300 words)

Do you have contacts/ collaborations with organizations outside your country related with epidemiology, public health, basic research or universities? Briefly describe the nature of such collaborations/activities; please include your collaborations/activities in Latin America and the Caribbean (Maximum 300 words)
Provide a list of activities that describe your professional profile, please include publications (maximum 5), technical reports, projects (include sponsor), and any other activity performed in the last five years. This is not an exhaustive CV, only include activities that allow us evaluate your experience, skills and professional production.
How do you envision your participation in a molecular epidemiology network? Are you aware of any regional effort in your field? (Maximum 300 words)
Do you speak/read/understand at an intermediate-advance level:
English ( ), French ( ), Portuguese ( ), Spanish ( )
Do you need visa to visit Venezuela? Yes ( ), No ( )
Do you have financial support for your airfare/lodging/ meals? Please provide an estimate of airfare (if needed) in order to attend the workshop.
Please send this form in word or as a PDF file to Dr. Raul Isea, workshop in molecular epidemiology, e-mail: bioinfo@cecalc.ula.ve or bioinfo@ivic.ve. Please request two professional references that should be send directly via e-mail. Those references should describe how they know you as professional and a critical statement about your work.
Only e-mail submission will be considered.
Tuition is 30 US Dollars or BS 60,000 (Venezuelan residents only). Fellowships are available for outstanding candidates. Tuition will not be exempted. All participants will be considered for fellowships automatically but acceptance in the workshop DOES NOT IMPLY that a fellowship will be provided. Fellowships include airfare (maximum 700 USD), lodging, local transportation, and meals. The workshop can be cancelled at any time by the organizers. 

Your academic credentials are important; however, your capacity of networking locally and regionally in molecular epidemiologic investigations will be given high priority. Professionals working in tuberculosis, dengue, malaria, salmonella, antimicrobial resistance, and vectors will be given priority.   

REGISTRATION SHOULD BE SUBMITED BY JUNE 11, 2004. SELECTED CANDIDATES WILL BE NOTIFIED ON JUNE 21. THE OFFICIAL LANGUAGE IS ENGLISH. 

WE ARE NOT AWARE OF ANY SPECIAL IMMUNIZATION REQUIREMENTS TO VISIT VENEZUELA. HOWEVER, WE STRONGLY RECOMMEND THAT YOU VISIT http://www.cdc.gov/travel/ AS SOON AS POSSIBLE.