Economic Epidemiology Advanced Study Institute, July 20 - July 31, 2009 and Workshop August 3 - 5, 2009

Advanced Study Institute and Workshop Application Form

Please apply by filling out the following blanks. Note that your application is complete when we have received:
1. this electronic application form
2. a statement of interest and commitment from you (uploaded through the website, .pdf and .doc files only)
3. a letter of recommendation (uploaded through the website, .pdf and .doc files only).
4. a letter from your mentor specifically committing to work with you upon your return from the Institute (uploaded through the website, .pdf and .doc files only).
The due date for receipt of ALL materials is March 1, 2009.

The due date for receipt of ALL materials is March 21, 2009 for Canadian applicants.

Participants should submit their applications to DIMACS:

When finished, press the "send" button at the bottom of the form. 



What are you applying to attend?

 Weeks 1 and 2 of the Institute (and following workshop)

 Week 2 only of the Institute (and following workshop)



Who are you?

           Your First Name: 
          Your Middle Name: 
            Your last Name: 



Your address?
    Institution:     
    Department:      
    Address Line #1: 
    Address Line #2: 
    Address Line #3: 
    Daytime Phone:    
    Cellphone:       



Your E-Locations?

                    E-Mail: 
                  Web page: 



What degrees have you completed?

Bachelors: 
  Area:            
  Institution:    
  Year Completed: 

Masters:
  Area:            
  Institution:    
  Year Completed: 

Ph.D.:
  Area:            
  Institution:    
  Year Completed: 

Other:             
  Area:            
  Institution:    
  Year Completed: 



Where are you in your current program of study?

  Area:  


 Year 1, M.S.
 Year 2, M.S.
 Year 3, M.S.
 Year 4, M.S.
 5+ Years, M.S.
 Year 1, Ph.D.
 Year 2, Ph.D.
 Year 3, Ph.D.
 Year 4, Ph.D.
 5+ Years, Ph.D.
 Other: 


Who will write a letter of recommendation supporting your application?


Title: 

Name: 
Phone: 




Who will be your mentor in continuing your work on your Institute research project?


Title: 

Name: 
Phone: 




Some optional information which we are required 
to track, since this is a federally funded program.  
You are not obligated to answer these questions:




Birthdate:  (format mm/dd/yy)


Gender:    M F


Ethnicity: 








Are you a U.S. Citizen
Permanent Resident
non-U.S.Citizen ?




If not a U.S. citizen or permanent resident, please list country of citizenship: 





What is your background in mathematical epidemiology?





Little or none (e.g. attended a few talks)


One or more courses


Other: 








Have you had coursework that includes SIR modeling?  
yes   
no

What calculus have you completed?
Differential calculus?  yes no
Integral calculus?      yes no
Multivariable calculus? yes no

Have you had any linear algebra courses?  
 none
 one course
 two or more courses

Have you had any statistics courses?  
 none
 one course
 two or more courses

Have you had any coursework in elementary differential equations in one and two variables?  
 yes
 no



List of relevant math and biology courses you have taken:
(please indicate if it is a grad level course or an undergrad level course)


     1: 
     2: 
     3: 
     4: 
     5: 
     6: 
     7: 
     8: 
     9: 
     10:
     11:
     12:



What is your proficiency with computer algebra and graphical software?



MatlabNone Beginner Intermediate Advanced



MathematicaNone Beginner Intermediate Advanced



gnuplotNone Beginner Intermediate Advanced 



Maple None Beginner Intermediate Advanced



Octave None Beginner Intermediate Advanced


Other:
DIMACS Home Page
Last modified Decmeber 17, 2008.