-scTICAIl.nrn! ldrd.r.6".,

a

l-hal(and's AnnuaI lnternational Traininq Course

(AITC)

Course information

"Thai Universal Health Coverage in Action"L9 * 30 August 2019

Closing date for dpplicdtion :7 tuly 2079

A. Background

Universal Health coverace (UHC) means that all individuals and communities recelve the health servicesthey need without suffering financial hardshlp. lt includes the full spectrurn of essential, quality healthservices, from health promotlon to prevention, treatment, rehabilitation, and palliatlve care.

UHC enables evelyone to access the services that address the most significant causes of disease and death,and ensures that the quality of those services is good enough to improve the health of the people whoreceive them,

Protecting people from the financial consequences of paying for health services out of their own pocketsreduces the risk that people will be pushed into poveffy because unexpected lllness requires them to useup their life savings, sell assets, or borrow - destroying their futures and often those of their children.

Achleving UHC 'ts one of the targets the nations of the worid set when adopting the SustainableDevelopment Goals ln 2015. countries that progress towards UHC wlll make progress towards the otherhealth-related targets, and towards the other goals. Good health allows children to learn and adults toearn, helps people escape from poverty, and provides the basis for long-term economic development. 1

ln vlew of UHC movement at global and-regional levels by many relevant partners, many developingcountries question its sustainability and achievement especially in relation to heatth financing spterns andhealth services provision. Thailand has no exception. A.lthough Thailand has achieved UHC slnce 2002,Thailand is still facing such problems as equity, service quality, accessibility, and escalation of medical care

lnternEtlonal expefts, Thulland does have lndivldual, instituttonat and networ.k capacities to shar.e wlth andlearn from other developing countries, in the region and beyond.

All Thal UHC partners l.e. Minlstry of Publlc Health, lnternational Health Policy program (lHpp), HealthIntervention and Technology Assessment Program (HITAP), ThaiHealth Foundation, Hospital Accreditationlnstitute, and National Health securlty office(NHSo] organizes a training workhop to share experience ofThal Unlversal Health Coverage under the training workshop "Thal Universal Health Coverage in action,,.

The tralning workshop aims at building capaclty of countries with high politicat commirment to achievingUniversal Health Coverage (UHc). Ultlmately, the workshop promotes South-South technlcal collaboratlonfor ensuring successful poliry formulation and implementation of Universal. Health Coverage (UHc). lnaddition, the workshop ls designed to meet the countrles'and participants, needs,

.

r httPs,//www"who.lnt/news-room{e-c!-sheets/detall/universa[-health-coverage-(uhc)[access 14 Feb 2019]

c.

Training workshop objectives

1. To share experience and challenges of Thal Universal Health Coverage in the real action,2. To exchange experience of other countries on their movement towards UHC

3. To build up networking among particlpants

Methods used during the training workshop

Several methods were applled to ensure that participants would gain maximum benef It from theworkhop, These methods are:-

1. Brief introduction by Thai policy maker2. Presentation on each topic byThai experts from several institutes.3. lnteractive discussion and exchange ofexperiences and perspectives by participants and speakers4, Group work to discuss and brain storm on key issues: the way forward and plan5. Short wrap up ofthe day before the session closed each dayto discuss and reflectional on how Thai

experience relates to participants' context.6. Field vfsit to a province to see the real situation and implernentation at provincial, district, and

primary care levels7. Essential materials for reading are prlnted and provided 1o the participantsB. Additional reading lists and references are provlded9- Country report by each country: participants prepare a report about their country which focuses

their health system development, health delivery system, health financing, health workforces,financial risk protectton mechanlsms and their national policy towards Ul-lC

D. Expected outputs of the train,ng workshop

7. The participants have an understanding on policy formulation, lmplementatlon and evaluation ofThai UHC and other countries'experlences on UHC.

2, Accordingtoparticlpants'countrycontext;theparticipantscanassessgapsforachievingUHCofthelr own country and can identify possible options for improving

3. Each particlpant would be developing networks with other participants and speakers

B.

E. Participantcrlteria

. Be from target countries where government has the national polioy and commitment to move towarduniversal Health coverage (UHC) to achieve lncluslve and sustainable health development

. Be nominated by their government / lnstltutes which involve ln moving toward universal Healthcoverage (UHC).

. Working ln the filed related to Universal Health Coverage

. Healthy both physically and mentally and able to fully participate ln the trainlng workshop for thewhole perlod,

r Sufftcientcommand of spoken and written Engllsh. As thts training workshop promotes nehivorking, participants of each country should be from various

Institutes, Ministry of Health, lnstltute of National Health Securlty/Health lnsurance, universities, etc.(note that one instltute may have not more ihan 2 participants and one country have not nrore than 4

participants)

F. Venue

The training workshop will be conducted in Bangkok and has field visits in provinces of Thailand

l. Further relevant inlormatlon is available at thc following addrcsses:

Thailand lnternational Developmcnt Cooperation Agency (TtCA)lJuman Resource Development Bureau (HRD Branch 2)The Government CornplexBuilding B (5outh Zone) Bth Il. r,

Chaengwauana Road, rak Si, dgagtok 10210Tel (662)203-5000 ext 43305E-mail: Sureerqt0 @mfA.eo.thWebsite: http :/ / www,tica, thaigov. net/main

National Health Security Office (NHSO)Ms. Wilailuk Wisasa, Program Coordinator Email: wilailuk.w@nhso.go-thMs, Papitchaya Wattanakrai Email; papichaya.w@nhso.go.thNational Health Security OfficeThe Government Complex, Building B

120 Moo 3 Chaengwattana Road, Lak Sl District, Bangkok 10210, ThailandTel: +66 2 747 4OOO,66 84 751 7639Fax: +66 2 743 9739Email; inlgrnhso@nhso.go,thWebsite: http;//www.nhs.o.go.thlenef

International Health policy program (IHpp)

' Dr. walelporn Patcharanarumol, Director of ll lpp, walaioorn(6ihop.thaisov.net. Dr. Warisa Panichkriangkrai, Researcher, warisa@ihpp.thaisov.net. Ms. Parinda Seneerattanaprayul , program Coordinator parinda@ihpp.thaigov.netlnternational Health Poiicy Program , Ministry of public Health.Tivanon Road, Amphur Muang, Nonthaburi province 11000, ThailandTel: +66 225902366-7Fax: +66 2 25902385We bsite: http://www.ihpptha igov.net

Health tnteruention and TechnologyAssessment program (HlTAp),

Health lntervention and Technotogy Assessment Program (HITAP), Ministry of public Health

11000, ThailandTel: +66 259O4549, +66 2 S90 4374-sFax!+662590-4369Ernail: info@hitap.netWebsite: http://www.hitap.net/enl1.

J, Tentatlve schedulo training workshop

Schedule of Day 1 - Day 10 on Ut{C training workshop

Dav 1

0900-0930 a

t

Welcome remarks and opening remark.

Briefine obiectives of this trainine workr'r? \

0930-10.45 Session 1 Achieving of Universal health coverage and sustalnable health development by2030

1045-7200 Session 2 Achieving of Universal health coverage: the role of evidence, social movement andpolicv commitment Thailand in real action..

1200-1300 Lunch

1300-1400 Session 3 Overview of Thailand's health system development and UHCr presentation based on "Health systems development in Thailand: a solid platform for

successful implementation of universal health coverage. The Lancet 2078;391:1205-23". Q&A and discussion

7400-753A Session 4 Country presentationr €ECh country: participants prepare a presentation about their country which focuses

their health system development, health delivery system, health financlng, healthworkforces, financial risk protection mechanisms and their national policy towards UHC(15 minutes/country)

1530-1600 and disc final qtrestions and answers of the da

Day 2 Study visit to National Health Office,::i;i.:'fini6.ll*:*

0900-0915 Welcome remark091s-0930 VDO oresentation "Welcome to NHSO" and 'Thai UHC"

0930-1200 Session 5 Governance of the UC Scheme: translatlng legislation lnto practicer National Health Security Act B.E. 2545 (A,D. 2002), process in developing the Actr lntroduction of UC Schemer Gntrarnrnro ctrrr^f rrra rnlac enrl Grncfinn< nf hlef inn:l l.larlih (orrrrifrr flffira /nlHqnl i

a

managing UCSchemelmplementing UC Scheme and challengeKnowledge & Capacity needs of NHSO for UCS managementRelationship and accountabilitv of kev stakeholders

a

a

1200-1300 Lunch

1300 - 1530 Session 6 Consumer Servlce and Consumer protectiono Consumer Serviceo Call Center 1330r Complain management

1300-1530 Sesslon 7 Core Buslness of NHSOr Core Business ofNHSO. Study visit at departments of NHSO to see the flow of activities :Customer Protection:

Call center, Claim department, lT department etc.

1530-1600 Summary and discussion, final questions and answers of thc dav

lec

Day 3.1.. .*.,t.,,.:,ltme. :.1

beoo{2oo "!,Ontgnt:':,':.-ri::.:....;. -:rirrirriira,:1,].:t,rrii i,..*t';,.rrrrti.lirir,,iri:'::ir{:1,:i!:i+tit:.::f.'.lli,l..:,_.-,.JL-._..1

Session B Public financlng management and provider payment. Resource mobilization, pooling and allocation. financing management: upstream & downstream

' How to design, enforce and monitor contractual agreement by purchaser organizationr Public financial management systems and changes over time

1200-1300 Lunch1.300-1430 Session 9 Development of benefit package: an evidence-based process

. Development of benefit package over time and the current scope of benefits

. Proces! of prioritization using evidence (HTA).

L430-t530 Session 1O benefit package management in action.r Process of new benefit package development.. Systern rnanagement for new benefit packageo Effectlve coverage of benefit package

1530-1600 Summary and discussion, final questlons and answers of the day

Sesslon 11 Registration systemI Beneficiary Enrollment system using national citizen individuat identlfication systemr Blrth rogistry to promotc universal Hcalth covoragrro National Health insurance beneficiary registration system. Health service provider registration systemSession 12 Primary Health Care and health prevention & promotion.r Evolution of primary health care. District Health System and Famity care teamlnter-links between PHC and secondaryandLunch

Session 13 Prornot€ Health prevention & promotlon in action. tiealth prevention & promotion in benefit package. Health prevention & promotion budget and payment.. Main actaon, management and

CSO in UCSchemer Role of CSO and LG in UC Schemeo People empowerment and Patient engagement. Localgovernrnent partlcipation and community Health Fund to promote Health

1530-1600 Summary and final questions and answers of the

Session X.5 Study vlsit at Dlstrict health facllltles in Contracting Unit for Primary care (CUP)in action.

o District Health System (DHS)/community hospital.r Registratlon and data update for UC patients at CUpr Service delivery systern: dlsease prevention, health promotion and curative services,'

including referral systemr Flow of fund from national to provincial level and then to CUp

visit District Health

1300-1600

te(

. Payment within CUP and the provinceManagement systcm: patient record and claiming

a lnterlinkages with distrlct hospitals, tecllnlgq]g!& audit process,

financial supportLu nch

Visit Health Centre as one Prlmary Care Unit (PCU) in CUP and Community Health Fund. Catchment area and management of health center. lntersectoral collaboration with localgovernrnent, schools and others. Registration and data update for UC patients/famlly folder and claim processlng. Seryice provision in health center and (up and down) referral system focused on

chronic disease management

' Flow of fund from CUP to Health center and payment within CUP and health center. Role of village health volunteer. Patient home visit activities by health centers: peritoneal dialysis for kidney failure

patient and rehabilitation of chronic bed ridden patientr Communitv Health Fund and its activities

Day 6 Provider of UC scheme

0900-0930 5ummary and discussion of fietd visit at secondary health care facilitates0900-1030 Session 16 Provider payment: capitation

. Capitation: design & method, process and the development of Thai capitation.

. Budgeting for capitation, lncluding payment capitation to the provider health spending,

by whom and pay for what and trend?o Capitation: estimation and application for purchasing primary care services: data and

technical requirementso Costing of hospital services: a foundation for development of sustainable provider

oavments1030-1200 Session 17 Provider payment Diagnostlc Belated Groups (DRGs)

. Overview on Thai DRG

. opportunity for developmentso Mprlirel codinp;nd DRG

a

Costing and calibration of relative weightProgramming steps of DRG

Auditine of DRG data

a

a

1200-1300 Lunch

L300-74L5 Session 18 Fund Allocation and Reimbursemento Claim system develop from paper claim through e-ctaim. UCS allocation and reimbursemente e-claim workflow

1415-1530 Session 19 Audit system. Account Audit according to criteria. Medical Audit according to standard guideline (Clinical Practice Guideline, CPG).. E-audit svstem

1s30-1600 I Summarv and discussion. final ouestions and answers of the dav

.er

0900-1200 Session 2O lCTto support ef{ective universal Health coverage UCSo lnformation Architecture and system to support UCS system and management. Data sharing - standardization of data elements and data mapping to link data between

NHSO and other schemes and the healthcare providers.r National data pooling of admission records using electronic transfer (web-based

apolicationl1200-1300 Lunclr

1300-1430 Session 21 Quality assurance and quallty improvement processes. Quality assurance processes, credentialing, Health facility standards (including staffing

guidelines). Hospital Accreditation

1.430-1530 Session 22 UCS Quality Control in action.. Context of quality improvement: concept, law, structure. Designed system for quality control. Ensuril8 standard quality & Motivating providers & professionals to improve the quality

l-s30-1600 Summary and discussion, final questions and answers of the dav

DeyB visit Health facilities

o800-1200 Session 22 Study visit at NHSO Regional Offlce and a provinclal hospital.

' Role of NHSo regional Officer lnterlinkages with health facilities ln the region, technlcal and financial support. Catchment area and management in regional and provincial levelr Registration and Cata update for UC patients at region/province. Service delivery system: disease prevention, health prornotion and curative services,

including referaI system. Flow of fund from national to regional, provinciat level and then to CUP

t record and claiming & audit

Visit ur:ban Health Centre as one Contracting Unit for Primary Care (CUP! and CommunityHealth Fund. Catchment area and management of health center

. Registration and data update for uC patients/family folder and claim processing

. Service provislon in health center and (up and down) referral system focused on chronlcdisease management

. Flow of fund from CUP to Health center and payrnent within CUP and health center

. Role of vlllage health volunteer

. Patient home visit activities by health centers: peritoneal dialysis for kidney failurepatient and rehabilitation of chronic bed ridden patient

r Community Health Fund management and its activities

o

Day 9

. ltme : ::

0900-0930 and discussion of field visit at secondary health care facilitates0930-1200 Session 23 Monitorlng and evaluating the outcome of UHC

. Equity in utilization, financial risk protection against catastrophic health expenditure and

impoverishment across rich and poor groups, equity in budget subsidies (benefitincidence analysis)

r Household level data platform such as national representative household surveys by

NSo e.g. SES, HWS, MICS, which facilitate regular monitoring of impact at householdlevels.

1200-l 300 Lunch

1300-14.00 Session 23 Monitoring and evaluating the outcome of UHC (cont'd)

' Administrative data platform for regular monitoring of clinical outcomes and practice

variations such as national lP dataset. Feedback loop from M&E results for policy fine tuning and reorientation. What lessons learned and how they could be replicated in your country

1400-1s.30 Session 24 Monitoring and evaluation of UCS

r Monitoring and evaluation frameworko Monitoring and evaluation of UCS financing, coverage, health service infra structure,

output outcome and household financial risk protection.1530-1600 Summary and discusslon, final questlons and answers of the day

Day 10

%%%%%%%%%%%%%%%%"/""/"%%%%%%%%'/,%%%%

I

i

:

I

1

@

TICAlndl..dH.rn.nonrl

Thaltand lnternatlona( Cooperatlon Agency

Ministry of Forelgn Affairs of Thaitand

GUIDELINES

for Thailand's AnnuaI lnternational Training Courses (AITC) Programme

1. About AITC

Reatizing a slgnificance ro(e of Human Resources Devetopment in economic and

sociat deveiopmen! the Roya[ Thai Government attaches great importance towards forging

cooperation through South-South Cooperation, particutarty through organizing short-term

training programmes. The Annua( lnternationa( Tralning Courses (AITC) is one of flagship

. programmes conclucted by Thaltanrt lnternational Cooperation Agenqr flCA. Aiming at

sharing Thailand's best practices and experiences to the wortd, the AITC programme offers

short-term training courses under a wide range of devetopment*etated topics.

AITC course is categorized under four ptus one themes. The hightighted themes is

Sufficiency Economy Phitosophy (SEP), the key factor behlnd Thaitand's achievement of

sustainabte devetopment in rnany areas. The other themes are areas in which Thaitand's

- best practlces can hetp address g(obat chattenges. They inc(ude Food Security, Cftmate

Change, Pubtic Heatth and other Sustainabte Deve(opment Goats (or SDGs) retated topics.

i. -- , -,.* ,Lo*eep,qr,.vith the cboamisrn"r.fsustdnable.level..FmenLageo{bsr.*bn alrJiorrse. rre. - -.,-*, , ...r.updatcd lcAutarty wlth the maln thonres reused ever/ three yearc. Duriug ZaLT - 2AL9,

TICA is pteased to offier more than 90 short-term tralning courses with the expected_number

of participants of nearty a thousand from devetoping countries around the wortd.

2, Ouatificatlons

2.1 Candidates must be nomlnated by centrat government agencies in a country

from the AITC eLigibte countriesAerritories Ust. (See "Llst of Etigib(e Countries,/Territories")

2.2 Candidates shoutd be an officer or agent (preferabty from government agencies)

currentty working ln the area retated to the training topic.

-2-

2.3 Candidates must have a degree and/or professional nrpnri..n." suitabte to

the training topic.

2,4 Candidates must have a good cornmand of Engtish.

2.5 lt is recommended that candidates be less than 55 years of age.

2,6 Candidates must be in good hea(th,

2.7 Nomination of femate candidates is encouraged,

2.8 TICA reseryes the rights to revoke fettowship offered to participants who are

pregnant during the period of trainlng.

3. Procedures for submission of nomlnations

3.1 Nomination must be made by centrat government agencies in charge of

nomination of nationat candidates (such as Ministry of Foreign Affairs) pr by retevant central

qovernment agencies for which the nominated candidates currently work, Nomination must

be in [ine with retevant rutes and regutations of the nominating countries/territories.

Each el.igibte countries/territories are invited to nominate up to two (2)

candidates per course.

3.2 The nomination must be supported by the fottowing two documenG;

: Appl.ication form

- Medical Report

Two (2) copies of orieinals of att forms du[y fitted out, counter-signed and

stamped by the authorized person must be submitted.

3.3 The nomination must be submitted to TICA through the Royal Thai Embassy/

Permanent Mission of Thaitand to the United Nations,/ Royal Thai Consutate-Genera[

accredited to el.igibl,e countries/territories. (See "List of El.igibl.e Countries/Territories")

3.4 Originats of nomination documents, duty fitted out, must be received no later

than a specified deadtine of each course.

3.5 Apptication form must be fitted in typed-btock tetter. Soft flte of the Apptication

Form and Medica[ Report Form can be found at

http://rarww.tica,thaigov.neVmain/contents/fites/lnformation-20161217-752$A-79537Z.pdf

-3-

4. Setectl.o_n_olcandidates

4.1 ln considerlng app(icatiorrs, particular attention shatt be paid to the candidates'

background, their current positlon in the service of tirelr Government, and practical use they

expect to make of the knowledge anrl experience gained from training on the return to their

Gorzemmer rt positions.

4.2 Se(ection of partlcipants ls also based on geographical distribution and gender

balance, untess priority ls set for particutar country/ group of countries,

43 TI,CA witt inform at[ successfut apptlcants through the Royat Thai Embassy/

Permanent Mission of Thatl.and to the United Nations,/ Royat Thai Consutate-Genera(

accredited to etigibte countries/tenitories. Moreove( name list of successfut appticants wiLt be

posted on TICA's u,ebsite approximatety two week before the cemmencement of the course.

4.4 No written not'ification witt be sent to unsuccessfut app(icants.

5. Duration qf the c.oursq;

Att AITC courses are carried out on a futt-time basis, The exact dat'es for each course

are as specified.

6. Attendance and Activities of the programnre.

6.1 Partlcipants are required to attend att activities organized during the course as

attendance in atl sessions is obtigatory. TICA reserves the rights to revoke its fe(lowship offer

or take appropriate action deemed appropriate in case a participant is in attendance of tess- than 90 percent of the trainlng hours.

6,2 Each AlrC course is designed according to its respective purpose. Most courses

6'3 Participants are required to prepare their country report on topic re[evant tothe training course prlor to the beginning of the course and prepare for their presentatlon

during the course.

7. Trave[ and financlal arrangements .

7.1 Successful candidates wi(t be offered an award which covers:

- Retum economy ctass aifare

- Accommodation for the duration of training in Thaitand

- Training attowance

- Social programme

4-

- lnsurance

- Airport rneeting service

7,2 Regutations on travet and financiat arrangements

- lnternational travel - Return economy ctass air ticket wiL( be provided v1a

the most direct and most economical route from the international airport at participant's

respective country/territory to the location where the course witt take ptace. The award

does not cover domestic travet cost in participant's respective country,

Transit destination witt be arranged according to a need for visa apptication to

Thaitand and/or on the most direct and most economicat route basis.

Atl. booking and change to the booking, lncluding a setting of date of anival and

departure, must be done by TICA onty. Ticket witL be issued in etectronic forn (e-tickeO onty.

Baggage attowance quota is in line with the airtines' poLicy. Any purchase for

extra baggage attowance is not covered by the award.

- Training attowance - Participants are entitted to receive a daity attowance in

the course of the programme at the rates established by the Royat. Thai Government which

is designed to coverthe cost of att meats, Therefore, the daity'altowance wit( be reduced if

meats are provided by the organizers. The at(owance is not a satary or an honorarium. The

a(towance is not Intended to cover the fe(tow's continuing expenses at home,

nor persona( expense. Therefore, it is suggested that each-participant shoutd bring some

pocket rnoney to cover their personal expenses. Attowance and att reirnbursement witl be

- lnsurance - Group Acciderrt arrd HoSpitatlzatiorr lrrsurance during the period of

training in Thaitand wiit be provided. The insurance does not cover pre-existing ittnesses and

outpatient medicaVdentat treatment. Participants are advlsed to obtain their own travet

insurance which is futly covered for any costs arislng from loss or theft of persona(

betongings.

- Accommqdation * Accommodation wi[t be provided to aLt participants during

their trainlng in Thaitand at designated hotet/accommodation. Any cost arising from

accommodation arranged by participants thernsetves cannot be reimbursed in atl case.

Accommodatlon does not cover any cost arising from participant's personal consumption

i-e. mlni bar, internationaVtocat catt or internet (uniess provided as comp(iment by

the hotel)

,5-

- Yra aflaqgentenl - Parlicipants witl be responsibte for obtaining appropriat'e visa

prior to their travct to 'l haitand, lf required. List of countries entitted for visa exemption and visa on

arrival to Thaitand can bc found at hltp://wtuw.consular.go.tMmaln/th,/custom]ze /62281-Summary-o{-

Countries-and-Territories-entitted-l'or.htnrt. TICA witt provide faciIitation to participants who

require visa application i,e, tiaising with the Royat Thai Embassy/ Consutate and advising on

appropriate procedure and necessary documents for vlsa application.

Participants must cover att costs arising from visa apptication i.e. visa fee,

travel cost to the Royat Thai Embassy/ Consulate, postat fee (in case visa apptication is

made by post,) transit visa fee (in case participants needs to appty for visa to ThaiLand at

a transit country). The visa fee can be reimbursed upon presenting an originaL receipt of

the fee but not exceed 2,000 THB.

Participants must not bring their famity members wlth them during their

training period, Participation In the training cannot be used as reference for visa application

to Thaitand of hiVher famity member.

- AirPort meeting serviie - Transfer to and from airport witt be provided to

participants. TICA wi( coordinate directty with the [imousine service to prepare for

the airport transfer.

B. Contac-t

For more information, ptease contact;

Bureau ofJnternationai Cooperatlon on Human Resouice Devetopment -

Thail.and lnternationa( Cooperation Agenry O|CA)

Chaengwattarra Rd. Lalsi District,

Bangkok 10210

THAII.AND

Website : u/w\ /.tlca.thalgov.net

Emai( : aitc6lmfa.go.th

TICA

ThaiLand lnternationaI Cooperatlon Agency

Mlnlstry of Foreign Affairs of Thailand

APPLICATION FORM

for Annual lnternational Training Course (AITC) Programme

A. PERSONAL HISTORY (pt.ur" ,tt .h a copy of your passport)

INSTRUCTIONS

The AITC app(lcation form ls composed of four parts, Part A to part C must be comp(eted

by candidate and part D by central government agenry*. A(t ffetds are mandatory.

Appticatlon form musl be fit(ed ln typej-btock tetter. The nomination must be supported by

thls app(lcation form and medica( report. Two (2) copies ol'orlgina(s of a(l, documents dul.y

fitted out, counter-signed and stamped by the authorlzed person must be submitted toTICA through the Royal. Thai Embassy,/ Permanent Misslon of Thaitand to the United Natlony'

Royat Thal Consutatedenerat accredited to eUglbte countrier/tenitories. Originab of nomlnation

documents, du{y fit(ed out, must be received no hter than a specifiecl deadtlne of each r.orrrse.

Soft flte of this app(lcatlon form can be downtoaded at http:,/wvwv.tlca.thalgov.netr For detai(ed informatlon on nomination process, p(ease see "GuideUne for AITC"

Course Name:

(Ptease attach

photograph

here)

Tltte Famity name Given name Other name Gender

O Mr.

O Ms.

O Mrs,

o

oo

Mate

Fema[e

City and country of birth Nationatity Date of birth

{DD/MWYY)

Age Maritat

Status

Retigion

Work address:

Tetephone No: (Country Code / Area Code / Number)

Home address:.

Te(ephone No: (country code / Area Code / Number)

Pagelof5pages

t

Emaii addrcssl

Preferred lnternationat Airport of depalture/arriva{. :

II2

It!L,it:Tii'tt.il

t

Contact. person in case of emergency:

Name: Re(ationship of this person to you;Tetephone No: Emait:

I.ANGUAGE

Engtish proflciency Read Write Speak

Excet(ent Good Fair Excetlent I cooJ Fair Excettent Good Falr

Mother tongue:

EDUCAIION

Name of lnstitution City / Country

Years atlended

Degrees, Diptomas

and Certificates

Specia(fletds

of studyFrom To

Have you ever been trained in Thaitand? lf yes, p(ease specifu course name and duration.

ONoO Yes, please speci!

Page 2 of5 pages

B. EMPLOYMENT (lmportant to give comp(ete lnformation)

Name of Organlzation/

lnstitution

l)erlod (from-to) Title of Position

C. EXPECTATIONS

Please describe your present worklresponsibitities and the practica( use you witt make of this training/study

on your return home in retation to the responsibiLities you expect to assume. (attached paper, if necessary)

I certify that my statements in answer to the foregoing questions are true, comptete and correct to the best

(a) condr.rct mysetf at att time in a manner. c:mPatil:te with my responsibititles as a participant of

the trainlng cou6e;

(b) spend futl time during the period of the programme as directed by TICA and training institution;

(c) refrain from engaging in in politicaL, commercial, or any other activities except those govemed by

the training programrne;

(d) submit a wetl-researched country report or any papers and make a prepared presentation as assigned;

(e) accept the ttavel arrangements and the financiat conditions re(ating to the fel.(owship provided by ihe

Royal Thai Government

(fl return to my home country upon the comptetion of my course of training.

Page 3 of5 pages

D' NOMINATIoN: To be compteted l:y authorized pcrson o[ the rrominating agerrcies of the AITC etiglbte

countries,/territories. (Se,e ,,Guldelirre for AllC,, for detail.ed inforrnation on nomirration.

I certify that;

(a) -lhe actlvities under this training witt contribute to the speciatization of the nominee. And in tl-re

case of a fettowship being granted to the nomlnee, fu[[ use woutd be made of the fet(ow'sexpedise in the fietd covered by her/his fel[owslrip;

(b) to the best of my knowtedge, alt information supplied by the nominee is comptete ancJ c,orrect;(c) to the best of my knowtedge, the nominee has adequate knowtedge and experience in retated

fle(ds and has adequate Engtistr proflclency for the purpose of the fel.towship ln Thaitand.

On return from the fe(towship, the nominee witt be emptoyed in the fo(towing position:

:

{

!\

tI

l

fficiatstamp:

Organization:

Officiat address:

Signature of responsibte government officia(

Name and titte of responslbte government officia[

Tetephone no,:

Facsimite:

ErnaiL

I

a

iIt

IIriti:ii,I

Page4of5pages

rNsr,ucn'xs "''tot ot'ol' ' --'_-

To be completed in apitol lelters by o registered medicol proclitiotrcr after thorough clinlcol ancl loboratoty exomlnation

including x-roy of chest.

Name of Nominee:

Nationa(lty:

Age : Gender :

1. ls the person exarnined at present in good hea(th and abte to work fut[ time?

2. ls the person examined abte physical.(y and mentat[y to carry on an intensive study programrne away fromherlhis duty station./home ptaceT

3. ls the person examined free from infectious diseases which cou[d present risks for both the candidate and

her/his contacts during the fettowships?

4. Does the person examined have any medicat conditions which might require treatment during her/his

fettowships?

5. (For femate nominee) ls the person examined pregnant?

!

"l

1

!

I

I

I

i

I

I

I certify that the person exa-mined is rnedicatty fit to undertake a tralnlng course in Ttraitarrd.

Physician signature (with stamp)

Fut[ name and address of examinlng physician:

Tetephone no.:

Emait:

Page 5 of5 pages