The Center for International Rehabilitation Research Information and Exchange

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CIRRIE MSI Exchange Program:
Application

The Center for International Rehabilitation Research Information and Exchange will consider requests for travel grants (including cost of airfare, lodging and meals) when all of the necessary information is supplied. Only accredited U.S. minority serving institutions of higher education are eligible to apply for this grant (see a list of institutions). Travelers are required to supply a current curriculum vita. Please refer to the general information sheet prior to completing this form. If you have questions as you fill out this application, please contact us by:

E-mail: ub-cirrie@buffalo.edu
Phone: 716-829-3141 ext.168

Applications are to be submitted by the U.S. traveler from an MSI or, by the MSI hosting institution on behalf of experts from other countries.

PLEASE type or print your application

Please check one:

__ Application from U.S. MSI Hosting Organization on behalf of experts from other countries

(complete sections A, C, D, E, F, G)

__ Application from traveler from U.S. MSI Institution going to another country

(complete Sections A, B, D, E, F, G)

  1. MSI Institution

    Name of College/ University and Department:
     

    Department Chair Name:
     

    E-mail address of Chair:
     

    Telephone number of Chair:
     

    Fax number of Chair:
     

    U.S. Department of Education Institution Designation:

    (Please check all that apply)

    __ Traditional Black College/University
    __ Hispanic Serving Institution
    __ Tribal College/University
    __ Minority Serving Institution


     

  2. Prospective MSI traveler:

    (please attach a current curriculum vita for traveler)

    Name:

     

    Department:

     

    Position/title:

    __ Faculty
    __ Doctoral Student

    (if Doctoral Student, please complete section B.1)

    Complete mailing address of traveler:

     

     

     

    Telephone number of traveler:
     

    Fax number of traveler:
     

    E-mail address of traveler:
     

    Expected dates of stay in the host country:

    (NOTE: 4-day minimum, 10-day maximum, engaged in collaborative activity)

     

    MSI traveler's primary field(s) of research:

     

     

    B.1: Doctoral Student Applicants only

    Major Advisor's Name:

     

    Telephone:

     

    Fax:

     

    E-mail:

     

    Letter of Support from Advisor:

    Please attach a signed letter of support from the doctoral student's major advisor. The letter should describe how the proposed travel will complement the student's current research and/or research-related goals, and how it will contribute to the student's capacity for research.

     

  3. Prospective international traveler invited to the MSI:

    (please attach a current curriculum vita for traveler)

    Name:
     

    Affiliation:
     

    Complete mailing address:

     

     

     

    Telephone (include country code):
     

    Fax:
     

    E-mail:
     

    Expected dates of stay in the U.S.:

    (NOTE: 4-day minimum, 10-day maximum, engaged in collaborative activity)

     

    Primary field(s) of research:

     


     

  4. Purpose of travel:

    (check all that apply)

    U.S. travelers, please arrange to have a letter sent to CIRRIE from the foreign institution(s) at which you will engage in collaborative activities.

    __ Planning or conducting research

    (Please describe the research project):

     

     

    __ Technical Assistance

    (Please describe the problems or questions that you expect to be addressed):

     

     

    __ Lecturing

    (Please describe the topics and audiences for the lectures):

     

     

    __ Joint publication

    (Please describe the type of publication and the probable date of publication):

     

     

    If the collaborative activities include a conference presentation, please complete the following:

    Title of Conference:
     

    Conference Location:

     

     

     

    Dates:
     

    Please specify the type(s) of presentation(s):
    __ Keynote
    __ Paper Presentation
    __ Round-table/symposium speaker
    __ Workshop
    __ Other:

     

    Approximate length of presentation(s):
     

    Topic/Title of presentation:

    (attach abstract)

     
     

  5. Traveler's Activities at Additional Sites:

    (if any)

    U.S. travelers, please arrange to have a letter sent to CIRRIE from the foreign institution(s) at which you will engage in collaborative activities.

    __ Planning or conducting research

    (Please describe the research project):

     

     

    __ Technical Assistance

    (Please describe the problems or questions that you expect to be addressed):

     

     

    __ Lecturing

    (Please describe the topics and audiences for the lectures):

     

     

    __ Joint publication

    (Please describe the type of publication and the probable date of publication):

     

     

    If the collaborative activities include a conference presentation, please complete the following:

    Title of Conference:
     

    Conference Location:

     

     

     

    Dates:
     

    Please specify the type(s) of presentation(s):
    __ Keynote
    __ Paper Presentation
    __ Round-table/symposium speaker
    __ Workshop
    __ Other:

     

    Approximate length of presentation(s):
     

    Topic/Title of presentation:

    (attach abstract)

     
     

  6. Expected Outcomes for MSI

    Please answer the following:

    (use back of this form or additional sheets if necessary)

    How will your current/future research benefit from this collaboration? What outcome(s) would you like to achieve?

    (Please be specific)

     

     

    How will the rehabilitation research community at your institution and in the U.S. benefit from this collaboration?

    (Please be specific)

     

     


     

  7. Tentative Overview of Collaborative Activity

    (Note: Travelers are expected to stay in the host country for a minimum of four (4) days and a maximum of ten (10) days, engaged in collaborative activity)

    Day 1:
     

    Day 2:
     

    Day 3:
     

    Day 4:
     

    Day 5:
     

    Day 6:
     

    Day 7:
     

    Day 8:
     

    Day 9:
     

    Day 10:
     

     

_____________________________

MSI Researcher's Signature (if applying for expert from other country to travel to the U.S.)
 

________

Date

 

_____________________________

MSI Applicant's Signature (if U.S. applicant is traveling to another country)
 

________

Date

 

_____________________________

Department Chair's Signature
 

________

Date

 

Please indicate how you (traveler) wish to be notified:

(check one)

__ Mail
__ Email
__ Fax
__ Phone

Mail or fax this signed form, the Hosting Agreement Form (one for each additional hosting organization/site) and curriculum vita of the traveler to:

CIRRIE
Center for International Rehabilitation Research Information & Exchange
University at Buffalo, State University of New York
515 Kimball Tower
Buffalo, New York 14214-3079 U.S.A.
Fax: 716-829-3217

Last revised: 12/2/2008