2019 DR LEE Jong Wook Fellowship Program Application Form

Korea Foundation for International
Healthcare(KOFIH)
2019 Dr LEE Jong-wook Fellowship
Program
Application Form
1. Clinical Experts & Disease Research Specialist Course

2. Health Administrators Course
3. High-level Officials Course
December 2018
1
Dr LEE Jong-wook Fellowship Program
Application Forms for

2019 Dr LEE Jong-wook Fellowship Program
1. Clinical Experts &

Disease Research Specialist Course
Form 1 : List of Applicant (for Ministry of Health)
Form 2 : Recommendation (for Ministry of Health)
Form 3 : Application (for applicants)
Form 4 : Study Plan (for applicants)
2
<Form 1> List of Applicant

*Application form must be TYPED in English, please do not write in hand-writing for legibility.
List of Applicant
Name
*Should be identical with Date of Birth Tel.
# Name on Passport Affiliation Position Specialty Email
(YYYY/MM/DD) (Mobile)
Last Middle Given
1
2
3
4
5
6
7
* Add additional lines if necessary.
※Application Timeline
# Process Deadline Note
1 Application Submission Feb 28 2019 *Submission to your MoH
2 Application Review Within 2 weeks from #1
3 Interview Within 2 weeks from #2
4 Decision Notification Within 1 weeks from #3
5 VISA Issuance 2 months taken
6 Start of Training 2nd week of June
* Please note that the dates are subject to change.

* Admissions decision will be notified to your individual e-mail.
* Deadline for Application: All required documents must arrive at the KOFIH headquarter in Seoul, Korea.
* Local deadlines may differ in each country so please make sure to confirm with the KOFIH staff in charge.
3
<Form 2> Recommendation Form *must be TYPED in English
Applicant Information
1. Name (last) (middle) (given)
2. Position / Title
3. Affiliation
Questions for Recommender

4. How long have you known the applicant and in what capability?
5. What do you consider the strength of the applicant?
6. What do you consider the weakness of the applicant?
7. Do you know any physical or mental condition which might affect the
applicant’s performance during invitational training in Korea? If yes, please
explain.
4
8. Please rate ability / attitude of the applicant in below table. (v)

Very Very
Good Fair Poor
Good Poor
Servant Leadership
Passion for Work and
Professional Attitudes
Ability and attitudes to take
actions for better health
Sense of accountability,
responsibility, and commitment
Ability to make visions for better
future
Attitude of perseverance and
diligence
Abilities and talents to become a
qualified educator and trainer
qualified policy maker and
conduct administrative work well
Level of Oral English
Level of Written English
9. Please comment on the ratings that you have assigned in #8 and make any
additional statement about applicants potential or personal qualities which
you believe would be helpful in considering the person's application for the
proposed program.
Recommender Information
2. Position or Title
3. Affiliation
4. Address
5. Tel 6. Fax
7. Email
(Date) 20 . . . (Signature)
5
<Form 3> Application Form *must be TYPED in English
3. Passport
2. Gender F/M *Valid
Number
Picture 4. Affiliation
5. Department
*Taken within last 6
months 6. Position/Title
7. Specialty
Field
8. Business
Address
9. Date of Birth YYYY/MM/DD 10. Religion
11. Home Address
12. Phone(Home) 13. Phone(Work)
14. Email 15. Mobile

16. SNS
(FB, Instagram etc.)
Name (last) (middle) (given)
Relation to
17. Emergency applicant
Contact
Address
Mobile
Credentials (List up to 3 in preferred order)

1.
Highest Degree 2.
3.
1.
License (No.) 2.
3.
1.
Certification (No.) 2.
3.
6
Language Proficiency
Language Speaking Writing Reading
English Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor
Korean Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor
Language Certificate
Language Test Score Valid Date Note
□IBT □ CBT □
English TOEFL
PBT
Korean TOPIK
Others
Academic Profile
Department /
Degree Name of Institution From To
Field of Study
BA YYYY/MM YYYY/MM
Master YYYY/MM YYYY/MM
PhD YYYY/MM YYYY/MM
YYYY/MM YYYY/MM
Former Training Experience in Korea or Other Countries
Year Length Purpose

Institution Country Funded by
(From ~ to) of Stay of Visit
7
Professional Career
Name of Year
Position Responsibility
Organization (From ~ to)
List of Major Publication and Research Activities

1
Major clinical practices you have performed in your specialty field

e.g. number of delivery, C/S operation, hysterectomy and laparoscope operation,
management of myomectomy etc. in case of OBGY
Protocols and/or practice for treatment of major diseases that are used
by your employed hospital
(the information will help instructors understand current trends of the medical treatment
in your country)
8
Copy of name card

(name, position/title, institute needs to be listed)
9
<Form 4> Study Plan *must be TYPED in English
Specialty/Field
The following information provided by you will enable your instructors to design the
customized curriculum for your training in Korea. It is of the utmost importance for your
instructors to fully understand your study goal and objectives so that maximum
relevance, efficiency and effectiveness of your clinical training can be ensured.
State precisely the knowledge and skills you want to acquire during your training.
Study Goal
1.
2.
3.
4.
5.
Based on your study goals as stated above, complete the following statement.
On completion of my training, I hope to be able to :
1.
2.
3.
4.
5.
6.
List up all new knowledge relevant to your specialization you want to learn in
detail
1.
2.
3.
4.
5.
6.
List up all new skills relevant to your specialization you want to learn in detail
1.
2.
3.
4.
5.
6.
10

2. Health Administrators Course
Form 4 : Study Plan (for applicants)
11

List of Applicant
Name
Last Middle Given
1
2
3
4
5
6
7
Application Timeline

3 Interview Within 2 weeks from #2

12
<Form 2> Recommendation Form *must be TYPED in English
2. Position / Title
3. Affiliation

explain.
13

Very Very
Good Fair Poor
Good Poor
Servant Leadership
future
diligence
proposed program.
3. Affiliation
4. Address
5. Tel 6. Fax
7. Email
14
3. Passport
Number
5. Department
7. Specialty
Field
8. Business
Address
11. Home Address

16. SNS
Relation to
Contact
Address
Mobile

1.
Highest Degree 2.
3.
1.
License (No.) 2.
3.
1.
3.
15
□IBT □ CBT □
English TOEFL
PBT
Korean TOPIK
Others
Academic Profile
Department /
Field of Study
BA YYYY/MM YYYY/MM
PhD YYYY/MM YYYY/MM
YYYY/MM YYYY/MM
Year Length Purpose

16
Professional Career
Name of Year

1
Major policy makings that you have designed or performed in your

specialty field
(etc. policy introduction case, case of providing healthcare with quality of service,
please be specific)
Protocols or manuals for management of major diseases that are used

by your employed hospital or government
in your country)
17
Copy of name card

18
<Form 4> Study Plan *must be TYPED in English
Specialty/Field
The following information provided by you will enable your instructors to design the
customized curriculum for your training in Korea. It is of the utmost importance for your
instructors to fully understand your study goal and objectives so that maximum
relevance, efficiency and effectiveness of your clinical training can be ensured.
State precisely the knowledge and skills you want to acquire during your training.
Study Goal
1.
2.
3.
4.
5.
Based on your study goals as stated above, complete the following statement.
On completion of my training, I hope to be able to :
1.
2.
3.
4.
5.
6.
List up all new knowledge relevant to your specialization you want to learn in
detail
1.
2.
3.
4.
5.
6.
List up all new skills relevant to your specialization you want to learn in detail
1.
2.
3.
4.
5.
6.
19

3. High-level Officials Course

*OPTIONAL
20

List of Applicant
Name
Last Middle Given
1
2
3
4
5
6
7
※Application Timeline

21
<Form 2> Recommendation Form *OPTIONAL *must be TYPED in English
2. Position / Title
3. Affiliation

explain.
22

Very Very
Good Fair Poor
Good Poor
Servant Leadership
future
diligence
proposed program.
3. Affiliation
4. Address
5. Tel 6. Fax
7. Email
23
3. Passport
Number
5. Department
7. Specialty
Field
8. Business
Address
11. Home Address

16. SNS
Relation to
Contact
Address
Mobile

1.
Highest Degree 2.
3.
1.
License (No.) 2.
3.
1.
3.
24
□IBT □ CBT □
English TOEFL
PBT
Korean TOPIK
Others
Academic Profile
Department /
Field of Study
BA YYYY/MM YYYY/MM
PhD YYYY/MM YYYY/MM
YYYY/MM YYYY/MM
Year Length Purpose

25
Professional Career
Name of Year

1
Major policy makings that you have designed or performed in your

specialty field
(etc. policy introduction case, case of providing healthcare with quality of service,
please be specific)
Protocols or manuals for management of major diseases that are used

by your employed hospital or government
in your country)
26
Copy of name card

27

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Korea Foundation for International

1. Clinical Experts & Disease Research Specialist Course

Application Forms for

1. Clinical Experts &

Form 1 : List of Applicant (for Ministry of Health)

Form 2 : Recommendation (for Ministry of Health)

Form 3 : Application (for applicants)

Form 4 : Study Plan (for applicants)

<Form 1> List of Applicant

* Please note that the dates are subject to change.

<Form 2> Recommendation Form *must be TYPED in English

Questions for Recommender

5. What do you consider the strength of the applicant?

6. What do you consider the weakness of the applicant?

8. Please rate ability / attitude of the applicant in below table. (v)

Level of Written English

1. Name (last) (middle) (given)

<Form 3> Application Form *must be TYPED in English

1. Name (last) (middle) (given)

9. Date of Birth YYYY/MM/DD 10. Religion

11. Home Address

12. Phone(Home) 13. Phone(Work)

14. Email 15. Mobile

Credentials (List up to 3 in preferred order)

English Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor

Korean Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor

Language Test Score Valid Date Note

Master YYYY/MM YYYY/MM

PhD YYYY/MM YYYY/MM

Former Training Experience in Korea or Other Countries

Year Length Purpose

List of Major Publication and Research Activities

Major clinical practices you have performed in your specialty field

Copy of name card

<Form 4> Study Plan *must be TYPED in English

Name (last) (middle) (given)

Application Forms for

2. Health Administrators Course

Form 1 : List of Applicant (for Ministry of Health)

Form 2 : Recommendation (for Ministry of Health)

Form 3 : Application (for applicants)

Form 4 : Study Plan (for applicants)

<Form 1> List of Applicant

# Process Deadline Note

* Please note that the dates are subject to change.

<Form 2> Recommendation Form *must be TYPED in English

Questions for Recommender

5. What do you consider the strength of the applicant?

6. What do you consider the weakness of the applicant?

8. Please rate ability / attitude of the applicant in below table. (v)

Level of Written English

1. Name (last) (middle) (given)

<Form 3> Application Form *must be TYPED in English

1. Name (last) (middle) (given)

9. Date of Birth YYYY/MM/DD 10. Religion

11. Home Address

12. Phone(Home) 13. Phone(Work)

14. Email 15. Mobile

Credentials (List up to 3 in preferred order)

English Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor

Korean Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor Excellent/Good/Fair/Poor

Language Test Score Valid Date Note

Master YYYY/MM YYYY/MM

<Form 2> Recommendation Form OPTIONAL must be TYPED in English