HE2RO Short Course Application Form 2014

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First name

Surname

Title

Postal address

E-mail address

Mobile number

Course of interest (choose one)

Short Course in Applied Cost and Cost‐Effectiveness Analysis for Public Health

Introductory Short Course in Epidemiology

Short Course in Program Monitoring and Evaluation

Workshop in Research Application to Policy

Current job title or academic programme (e.g. “Data analyst” or “MSc in Epidemiology”)

Current institutional affiliation (name of employer or university) (e.g. “Gauteng Department of Health” or “Wits University")

Department or division within institution (e.g. “TB Division” or “Department of Economics”)

Highest academic degree already completed and major or field of degree

Prior coursework (studies) in epidemiology, health economics, and/or policy analysis

Prior job experience in epidemiology, health economics, and/or policy analysis

Software proficiency: Excel or other spreadsheet

Not proficient

Somewhat proficient

Highly proficient

("Proficient” means that you know how to use the program to conduct analysis.)

Software proficiency: SAS, STATA, or other data analysis program

Not proficient

Somewhat proficient

Highly proficient

("Proficient” means that you know how to use the program to conduct analysis.)

Software proficiency: CSPro, EpiInfo, or other database program

Not proficient

Somewhat proficient

Highly proficient

("Proficient” means that you know how to use the program to conduct analysis.)