HIDEYO NOGUCHI AFRICA PRIZE NOMINATION FORM

Please fill out the attached HIDEYO NOGUCHI AFRICA PRIZE NOMINATION FORM with the necessary information and submit it with the supplementary documents listed below.


* Up to 5 files (maximum size limit for each file is 8MB) can be attached using this form.
In case you need to attach 6 or more files, please compress your files to the ZIP format so that the total number of files is no more than 5.

- Please provide a brief description of the nomineefs contributions in the area of medical research or medical services within the context of the Prizefs concept. (about 50 words)
- Please present a brief biography including academic, administrative and/or research positions, awards and/or recognitions.
- Please outline how and why the research/activity of the nominee has contributed to the advancement and improvement of measures against infectious and other diseases prevalent in Africa, if any. (within 2 pages)
- Please provide the titles of publications that represent the nomineefs contributions. (Please mark 4-5 of best publications among them if there are many.)
- Please arrange for other specialists familiar with the nomineefs work to provide supporting letters. (up to 5 letters)

Please note that nomination form and supplementary documents format (sample) may be downloaded either from the Cabinet Office website or from the JSPS website.

ELIGIBILITY (Medical Services):
- In the case of nominating an organization, nominations are limited to one currently active organization.
- Nominations are in principle to be one individual or one organization per activity. Under exceptional circumstances, however, when more than one individual or organization work as a team, a maximum of three individuals or organizations will be considered.

DEADLINE:
The nominations and supporting letters must reach the respective secretariat by no later than August 20th, 2021.

Any personal information contained in the submitted nomination form and supplementary documents will be handled with the utmost care in accordance with the Act on the Protection of Personal Information, and will only be used as part of the selection process for the Hideyo Noguchi Africa Prize (including the provision of personal information to private-sector companies or other external partners for the purpose of carrying out consigned electronic data processing and data management). By submitting these nomination documents, you hereby agree to the use of said personal information for the aforementioned purposes.

If you agree with the above, please fill in the blanks below and click the gConfirmh button.

Required fields are marked *.

Appropriate Category *
* For Medical Research nominations, please use the JSPS electronic application system.
Nominee Information

Name *

In case medical services are provided by a team, please input the name of one representative. Names of other individuals should be input in the gSpecial Notesh field below. (A maximum of three individuals or organizations including the representative will be considered.)
Gender *
Areas of Nominee's Contribution keyword 1 *

* input 3-5 keywords, one for each field
Areas of Nominee's Contribution keyword 2 *

Areas of Nominee's Contribution keyword 3 *

Areas of Nominee's Contribution keyword 4

Areas of Nominee's Contribution keyword 5

Designation *

Organization Name *

Address *

Telephone *

Fax

E-mail Address *

(Please enter email address once again for confirmation.)

Nationality *

Date of Birth *

MM/DD/YYYY
Nominator Information

First Name *

Last Name *

Designation *

Organization Name *

Address *

Telephone *

Fax

E-mail Address *

(Please enter your email address once again for confirmation)

Supplementary Documents

Attach Document File 1 * You can attach up to 5 files at the time of submission. *Maximum size limit for each file is 8MB.

Attach Document File 2

Attach Document File 3

Attach Document File 4

Attach Document File 5

Special Notes

Confirm *
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