Workshop on Monitoring and Evaluation of Malaria Programs 29th May - 9th June 2017
APPLICATION FORM
Title
Surname
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First name
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Gender
Current position/job title
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Institutional affiliation
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Institutional mailing address
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Business telephone
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Mobile telephone
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E-mail address
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Nearest airport
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Country of citizenship
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City & country of birth
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Date of birth
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DD
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YYYY
Country of passport (if different than country of citizenship)
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Passport number
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Select course option (Only participants who have previously completed an M&E course may apply for option 2)
If you choose option 2 course, please list the name of the monitoring & evaluation course completed, the date of completion, and the content learned:
Your answer
Post-Secondary Education (Begin with most recent and include Dates, Institution attended, Major subject and Degree completed) for example: 1999 -2003, University of Ghana, Biology, master in Biology,.............)
Your answer
Relevant work experience (Begin with most recent and include Dates, Titles, Employer, City for Example: 2005-2009, medical, doctor Ndjamena,.............. )
Your answer
Describe your present duties and responsibilities, including both teaching and research, with specific emphasis on work-related monitoring and evaluation activities:
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List all program monitoring and evaluation experience (Please provide the date, the name of the program, the funding source, your role in monitoring evaluation effort and the location for example: 1999-2000, NMCP, Ministry of health, M&E Officer, Accra,..... )
Your answer
Does the organization where you currently work receive any funding from USAID for the project that you work on?
Are you primarily involved in monitoring and evaluation at the (check one):
In which type of organization do you currently work?
How many years in total have you been working professionally?
Your answer
Have you ever prepared an M&E plan alone or with colleagues, before attending this workshop?
Have you been involved with actual implementation of monitoring activities before attending this workshop?
Have you ever worked on an impact evaluation, in other words, an evaluation to measure “cause and effect” of the program?
For how many years have you been doing monitoring & evaluation in your work? No. years of M&E experience:
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What knowledge and skills do you hope to gain from this training?(Please list at least three objectives)
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List your publications, particularly in field relevant to the workshop (Date,Title of publication, where it was published for example: June 2006, Malaria prevalence in Burkina,Tropical Disease,...).
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List below any scholarships, fellowships, grants, contracts, or other awards you have received, including grants to attend international conferences, workshops, or seminars.Please specify which if any awards are current, and indicate expiration dates for example: 2016-present, USAID,.....
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For our records, please tell us how you heard about this workshop:
FUNDING FORM
I will be funded by the following sponsoring agency (Name of funding organization, Contact person/Title telephone and email address..)
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I would like to apply for full funding (Tuition and fees, Travel, Insurance, Visa, etc.) from theMEASURE Evaluation project. MEASURE Evaluation provides few fellowships and they are very competitive applicants are encouraged to seek other funding sources.
ESTIMATED WORKSHOP EXPENSES; (checkmark your option)
Please describe your relevant education, research, and/or work experience, and indicate how your participation in the Workshop will benefit your future work. (250 word maximum).
Your answer
One reference (separate form) must be submitted in support of your application.The reference form should be completed by your referee no later than April 14, 2017. Please copy and email this link to your referee https://goo.gl/forms/C6r2UM0GPGnavRvo2 . Please list below the name of the referee you have selected.
Your reference ( Name, title, Email date you requested the reference)
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