CIRRIE Standard Exchange Program:
Application

The Center for International Rehabilitation Research Information and Exchange will consider requests for travel grants when all of the necessary information is supplied. 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 hosting organization, not the traveler.

PLEASE type or print your application

Please check one:
___Hosting Organization Outside the U.S.
___U.S. Hosting Organization

1. Primary Hosting Organization:

   Name of the organization or full name of OSERS (U.S. HOSTS ONLY) funded project:
    

   Complete mailing address:

    

    

    

   Name of organization director or name of project director or principal investigators of OSERS (U.S. HOST ONLY) funded project:

    

   Telephone (include country code):
    

   Fax:
    

   E-mail:
    

   Project funded by:
   

   (U.S. HOST ONLY)
   __ NIDRR
   __ OSEP
   __ RSA

   Grant number:
   

   (U.S. HOST ONLY)
   
    
    
2. Prospective traveler: (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 host country:
   

   NOTE: Travelers are expected to stay in the host country for a minimum of seven (7) days, engaged in collaborative activity.
    

    

   Please describe the traveler's primary field of rehabilitation/disability research.

    

    

    

   
    
3. Purpose of Travel: (Check all that apply)
   

   __ 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)
   
    
    
4. Activities at Additional Sites (if any)

   __ 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. Expected Outcomes: Please answer the following:
   
   (Use additional sheets if necessary)
   
   

   • How will your project benefit from this collaboration? What outcome would you like to achieve?

      

      

      

   • How will the rehabilitation research community in your country benefit from this collaboration?

      

      

      

   • What experience or expertise does this person have that will benefit your project?

      

      

      

6. Tentative Overview of Collaborative Activity During Stay in Host Country

   Please attach a tentative, detailed schedule for your guest's visit, indicating the collaborative activities in which the guest will be engaged on each day of the visit.
   

   (Note: Travelers are expected to stay in the host country for a minimum of seven (7) days, engaged in collaborative activity)

I understand that CIRRIE will pay for airfare ONLY and that a brief report is required within 30 days of completion of travel by both the traveler and hosting organization. Our project/organization/center will be responsible for lodging, meals and other costs associated with this travel.

________________________________________________

________________________________________________

________________________________________________

__________________

Please indicate how you wish to be notified:

__ 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