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All Africa Leprosy, Tuberculosis and Rehabilitation Training Centre
ALERT, Training Division, P.O.Box 165, Addis Ababa, Ethiopia
Tel.: +251 1 211341, Fax: +251 1 211351, Fax Executive Director: +251 1 211523
E-mail: leprosytb@telecom.net.et
Application
for Training
Please
use a typewriter, or write in black pen using BLOCK letters.
Name of the course:
Date from:
To:
Sponsoring agency
Name:
Address:
Candidate
details
Full name (as in the
passport):
Nationality:
____________________ Date of birth: ____________ Male 1
Female 1
Address
for correspondence:
Daytime phone no.:
Fax no.:
E-mail
address:
Education
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Year when ended
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Institution (name, place)
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Qualification
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Main field of study
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Secondary education
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Professional or university qualification
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Post graduate
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Have you previously been on
a course at ALERT?
Yes 1
No 1
Employment:
Name
of organisation:
Description
of your present job:
Starting
date:
Address:
Previous jobs:
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Date (from and to)
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Job title or description
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Employer
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TB
and Leprosy Experience:
Tick the areas in which you
feel competent:
1
Diagnosis of leprosy 1
Diagnosis of TB 1
Classification of leprosy
1Case finding 1
Case holding 1
Management of the programmes
1
Training 1
Supervision 1Laboratory work
1
health education 1
Setting objectives
What is your objective in coming to the
course?
Duties
expected following the training
What
level will you be working at?
1
region or above 1district or below
Type
of programme: 1
leprosy only
1
TB only 1
integrated programme
Tasks: 1
Clinical management 1
Control 1
teaching
Candidate's name: ______________________
Signature: ____________ Date __________
Employer's
name: ______________________
Signature: ____________ Date __________
Sponsor's name: ______________________ Signature: ____________
Date __________ |