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Application form to join GABRIEL as member Part A – Administrative information Name of organization / institution : ………………………………………………………… Street address : ……………………………………………………………………………… Postal code : …………………………………………………………………………………. City :……………………………………………………………………………………………. Country of applicant : ………………………………………………………………………… Name and title of responsible person : …………………………………………………….. Telephone (incl. country code) : ……………………………………………………………. Email : …………………………………………………………………………………………. Website : ………………………………………………………………………………………. Part B – Description of your institution (department, activities, staff that will be involved in the GABRIEL programs) ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 1 Application form to join GABRIEL as member ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 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………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 2 Application form to join GABRIEL as member Part C – Description of your current research activities ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 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………………………………………………………………………………………………….. 3 Application form to join GABRIEL as member Part D – Description of your motivation to join GABRIEL ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 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Your institution wish to participate to the following GABRIEL research program : TB Acute Lower Respiratory Infection Part E – Country information E1. General statistics Total population : ……………………………………………………………………………. Gross national income per capita (PPP international) : …………………………………. Life expectancy at birth m/f (years) : ………………………………………………………. Total expenditure on health per capita (Intl $, 2006) : …………………………………… Total expenditure on health as % of GDP (2006) : ………………………………………. E2. Country health data information List the 3 main public health problems : 1………………………………………………………………………………………………… 2………………………………………………………………………………………………… 3………………...………………………………………………………………………………. Specify and develop the 3 main needs of your country in term of research capacities : ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. ………………………………………………………………………………………………….. 5 Application form to join GABRIEL as member E3. Country TB profile Incidence : All forms of TB (thousands of new cases per year) : …………………………………… All forms of TB(new cases per 100 000 pop/year) : ……………………………………. Prevalence : All forms of TB (thousands of cases) : ……………………………………………….. All forms of TB (cases per 100 000 pop) : ………………………………………………. Mortality : All forms of TB (thousands of deaths per year) : ………………………………………… All forms of TB (deaths per 100 000 pop/year) : …………………………………………. E4. Country ALRI profile Incidence : …………………………………………………………………………………….. Prevalence : …………………………………………………………………………………... Mortality : ……………………………………………………………………………………… Appendices (to be fill in and sent as attachments in the application) A. Good Laboratory Practices Questionnaire B. Lab capacities and equipment questionnaire 6
