APPLICATION FORM

APPLICATION FORM
1. Title*

Mr.Mrs.Ms.Dr.Other
2. Name*

First NameSurname
3. Other names:
4. Gender*

MaleFemale
5. Current position/job title
6. Institutional affiliation
7. Institutional mailing address
example@example.com
8. Business phone number:

Country CodePhone Number
9. Mobile phone number:*

Country CodePhone Number
10. Personal Email:
example@example.com
11. Nearest airport
12. Country of citizenship
13. City & country of birth
14. Date of Birth*

DayMonthYear
Date
15. Country of passport
if different than country of citizenship
16. Passport number
17. Select course option (Only participants who have previously completed an M&E course may apply for option 2)

Option 1 - SM&E Fundamentals + GIS + Malaria surveillance trackOption 2 - SM&E Fundamentals + GIS + Evaluation Methods for malaria trackOption 3 -GIS + Malaria surveillance track onlyOption 4 - GIS + Evaluation Methods for malaria track onlyOption 5 – GIS track onlyOption 6 – Evaluation Methods for malaria track onlyOption 7 – Malaria surveillance track only
18. If you chose an option 3-7 track, please list the name of the monitoring & evaluation course completed, the date of completion, and the content learned (send proof via m.e.malaria@gmail.com)
19. Post-Secondary Education (Begin with most recent and include in the following order: Dates, Institution attended, Major subject and Degree completed) for example: 1999-2003, University of Ghana, Biology, MSc Biology, etc.)*
20. Relevant work experience (Begin with most recent and include in the following order: Dates, Titles, Employer, and City for Example: 2005-2009, Medical Doctor, ABC Medical Centre, Ndjamena, etc.)
21. Describe your present duties and responsibilities briefly, including both teaching and research, with specific emphasis on work-related monitoring and evaluation activities:
22. 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, etc.)
23. Does the organization where you currently work receive any funding from USAID for the project that you work on?
24. Which level are you primarily involved with in terms of monitoring and evaluation? (Check one)*

National levelProvincial/regional levelDistrict levelSub-district levelOther
25. In which type of organization do you currently work?*

Donor organizationNon-governmental organizationGovernmental organizationOther
26. How many years in total have you been working professionally?
27. Have you ever prepared an M&E plan alone or with colleagues, before attending this workshop?
28. Have you been involved with actual implementation of monitoring activities before attending this workshop?

YesNoOther
29. Have you ever worked on an impact evaluation, in other words, an evaluation to measure “cause and effect” of the program?

YesNoOther
30. For how many years have you been doing monitoring & evaluation in your work? No. of years of M&E experience?
31. What knowledge and skills do you hope to gain from this training?(Please list at least three objectives)
32. 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, etc.)
33. Type in a research title you working on or intend to work on for possible mentorship
34. 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, etc.
35. Please tell us how you first heard about this workshop:*

Communication from University of Ghana, School of Public HealthUniversity of Ghana, School of Public Health WebsiteMEASURE Evaluation websiteCommunication MEASURE EvaluationRoll Back Malaria monitoring and evaluation listservYour employer or colleagues at your workplaceAn alumni of the workshopOther
FUNDING

Self sponsoredI will be sponsored by the following sponsoring agency (Name of funding organization, Contact person/Title telephone and email address.)
FUNDING: If you will be funded by the following sponsoring agency, kindly provide these information:Name of funding organization, Contact person/Title telephone and email address.
Name of funding organization
Contact person

First NameLast Name
Phone Number*

Country CodePhone Number
Email
example@example.com
ESTIMATED WORKSHOP EXPENSES

August 21 – August 25, 2023: SM&E Fundamentals + GIS + 1 Track. Tuition and fees (include course materials, certificate, accommodation, breakfast and lunch for the duration of the workshop. This does not include travel or other expenses) US$3,850August 28 – September 1, 2023: GIS + 1 Track. Tuition and fees (include course materials, certificate, accommodation, breakfast and lunch for the duration of the workshop. This does not include travel or other expenses) US$3,100September 4 – September 8, 2023: Track options (i.e. GIS/Evaluation/Surveillance) Tuition and fees (include course materials, certificate, accommodation, breakfast and lunch for the duration of the workshop. This does not include travel or other expenses) US$2,000
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).
One reference (separate form) must be submitted in support of your application. The reference form should be completed by your referee no later than July 19, 2023. Please list below the name of the referee you have selected.
Title

Mr.Mrs.Ms.Dr.Other
Your reference*

First NameLast Name
Phone Number*

Country CodePhone Number
Email*
example@example.com
Date you requested the reference (DD/MM/YYYY):*

DayMonthYear
Date
Have you shared the link below with your referee to complete the reference form? https://form.jotform.com/211583548251557 *
Should be Empty:

APPLICATION FORM

FUNDING: If you will be funded by the following sponsoring agency, kindly provide these information:Name of funding organization, Contact person/Title telephone and email address.

One reference (separate form) must be submitted in support of your application. The reference form should be completed by your referee no later than July 19, 2023. Please list below the name of the referee you have selected.