PRESTASI Application Form

Applicant Name: YUDI ARIESTA CHANDRA

Field of TrainingProgram to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides opportunities for Indonesians to earn Masters degrees which focus on areas that are relevant to the achievement of USAID/Indonesia and Government of Indonesia development goals. PRESTASI II offers fields of training as follows: Education, Health and Environment. Indicate your preference(s) by filing in the number 1-3 on the left column. The number should reflect your priority rank of the proposed field of study. You may choose up to 3 options under the same Field of Training.Education U.S. University

Information Communications Technology (ICT) in teaching methodologies as it relates to vocational or higher education

Curriculum development in vocational and technical education

Workforce development

Educational leadership in vocational, post-secondary, community or technical colleges and higher education

Education policy in vocational, post-secondary, community or technical colleges and higher education

Health U.S. University

Public Health

Biostatistics / Epidemiology

Infectious Diseases and Vaccinology

Maternal child health and reproductive health

Health promotion and behavior

Hospital Management

Health system strengthening: health financing/economics, health management and policy, data information management, logistic supply chain management and health insurance

Nursing Management and Health Care

Medical laboratory science

Health Indonesian University

Public Health

Biostatistics / Epidemiology / Field Epidemiology

Maternal child health and reproductive health

Health promotion and behavior

Hospital Management

Health system strengthening: health financing/economics, health management and policy, data information management, and logistic supply chain management

Occupational safety and health

Drug management and policy

Nutrition and Health

Environmental Health

Nursing and health care

Environment U.S. University

Water and Sanitation

Sustainable Forest Management, Agro-forestry and Community Forestry

Marine and Coastal Zone Management

Agribusiness, Agricultural Economics and Agricultural Biotechnology Policy

Public Policy (in economic sector)

Environment Indonesian University

Water and Sanitation

Sustainable Forest Management, Agro-forestry and Community Forestry

Marine and Coastal Zone Management

Agribusiness, Agricultural Economics and Agricultural Biotechnology Policy

Public Policy (in economic sector)

List of Required Documents

Mandatory DocumentsPlease put check mark () if you have attached the following documents in support of your application

1.Completed and signed application form1 original and 3 copies

2.Certified Undergraduate Certificate1 original and 3 copies

3.Certified Undergraduate Academic Transcripts1 original and 3 copies

4.Recent photographs (4 x 6, B/W or color)4 copies(attach to each copy of application form)

5.Recent Curriculum Vitae (in English)4 copies(attach to each copy of application form)

6.Copy of valid national ID Card (KTP or Passport)1 copy

7.Valid TOEFL ITP or TOEFL IBT or IELTS scores result1 copy

8.Original Reference Letters, in sealed envelopes3 copies

Supplementary DocumentsPlease put check mark () if you are attaching the following documents in support of your application

9.Copy of certificates and awards1 copy

10..Copy of article, journal, research, or cover page of your publication etc.1 copy

Important Do not submit original documents. Application forms and attached documents will not be returned. No mandatory and/or supplementary documents can be delivered separately from the application forms, except the Reference Letters. You do not need to translate the academic transcript and certificate to English.

To expedite the process, please pay attention to the following instruction below:Put together all documents and arrange them into 4 separate sets. Each set should contain documents as described above and every set should be in the same order. Please see below example: Original Form Copy 1 Copy 2 Copy 3(No 1 10) (No 1 5) (No 1 5) (No 1 5)Please do not bind the documents. Please use paper clips to expedite the dividing process.

From where did you first hear about PRESTASI?Newspaper or magazineTelevision

Brochure or flyerRadio

Education Fair or presentation sessionInternet or mailing list

Social media (Facebook or Twitter)Advertisement at university

Other, please specify: _________________________________________

Application Delivery

Application packages should be delivered via post / mail or hand-delivered to IIEF office to the below address:USAID Scholarship PRESTASI ProgramMenara Imperium, 28th Fl. Suite AJl. HR Rasuna Said Kav.1, Kuningan, Jakarta 12980

The application packages should arrive at IIEF office at the latest on March 14, 2014, before 4.30 PM. No documents are allowed to be sent via email or fax. Late or incomplete application will not be considered.Early application submission is highly recommended.

1. PERSONAL INFORMATIONPlease give your personal details exactly as it appears on official documents (National ID, Passport, Birth Certificate, etc.). Each field is mandatory.

First NameYUDI

Middle NameARIESTA

Last NameCHANDRA

National ID Details: (check only one box below)

KTP PassportNo : 1806040904880002

Expiry Date (DD/MM/YY) : 09/04/18Date of Birth (DD/MM/YY)09/04/88

Place of BirthTEKAD

GenderMale Female

NationalityINDONESIAN

Residential Address :

Jalan Karet No. 09 A RT 01 RW 05 Margonda RayaKelurahan Kemiri Muka, Kecamatan BejiCityDEPOK

ProvinceWEST JAVA

Postal Code16423

Home phone no.N/AMobile no.+62 852 6900 5130

[email protected] StatusSingle Married Widow/widower

2. PHYSICAL IMPAIRMENT INFORMATION (if applicable)

Category Visual impairment Hearing impairment Physical impairment

Please specifyN/AN/AN/A

Special needs identification (Please identify support that you need from USAID PRESTASI, in order to be successful in your future study. For example: wheel chair, special communication devices and Braille computer)

N/A

3. EMERGENCY CONTACTDetails of a person that we can contact in case of emergency. You should provide 2 emergency contacts.

NameRENALDI


Jalan Puskesmas No. 515 RT 04 RW 02, Blok IIIDesa Tekad, Kecamatan Pulau PanggungCityTANGGAMUS

ProvinceLAMPUNG

Postal Code35379

Home Phone N/A

Mobile Phone+62 813 690 45 212

Email [email protected]

Relationship to youFATHER

NameAYU PUSPITASARI


Jalan Puskesmas No. 515 RT 04 RW 02, Blok IIIDesa Tekad, Kecamatan Pulau PanggungCityTANGGAMUS

ProvinceLAMPUNG

Postal Code35379

Home Phone N/A

Mobile Phone+62 822 801 456 98

Email [email protected]

Relationship to youSISTER

4. ENGLISH LANGUAGE PROFICIENCYPlease check only one box below and attach the copy of certificate. Prediction test is not allowed.

Type of test TOEFL ITP TOEFL IBT IELTSOverall score457

Date of test taken(DD/MM/YY)28/12/2013Test Location IES FoundationSenayan Trader Center (STC) Building No.03 - 103 Jalan Asia-Afrika, Jakarta 12720

5. PROPOSED FIELD OF TRAININGPlease refer to the Field of Training section on page 1 in this Application Form. You are allowed to propose up to 3 choices in rank order. The proposed field of study must be under the same Field of Training. If you are awarded the scholarship, you may not be permitted to make changes.

First Priority

Field of Training NURSING MANAGEMENT AND HEALTH CARELocation of study* Indonesian University U.S. University

I chose this study because it is linear with undergraduate education that I took and the most important is the study in this area will support the career and my job as a teacher in the field of nursing. It certainly will help me in developing nursing science in my country through education and research which I will do ahead.

I hope by study nursing and health care management, I can apply it by develop a management system of nursing especially in the field of emergency psychiatry that became focus of my teaching, because the system which currently being used in my country highly needs to be developed.

Second Priority

Field of Training PUBLIC HEALTHLocation of study* Indonesian University U.S. University

Changes in the current health care paradigm is not only focused on hospital services but also in the community and then implemented in the field of nursing including psychiatric nursing. By studying public health I would like to learn more about how to protect and improve the health status of the community through the organization of community resources that are effective, efficient and based on professionalism.

The United States is one of the countries with best community health care system in the world, so I am confident with the knowledge and experience of public health study will be implemented in my country, particularly in improving the mental health community.

Third Priority

Field of Training HEALTH SYSTEM STRENGTHENING : HEALTH FINANCING/ ECONOMICSLocation of study* Indonesian University U.S. University

At the beginning of this year, Indonesia has recently implemented national health insurance system. Of course, because this system highly new, it will take a lot of improvement. Various studies development urgently needed in improving the quality of the national health insurance system. On the other hand studies on health financing system which is the basis of this system not very developed in Indonesia. The United States is the country with best social security systems in the world with medicare and medicaid programs, so I believe it is appropriate to learn about this study in the United States, then after I completed the study and returned to my country, I believe the knowledge I have will be used in improving health insurance system run by my country.

6. PROPOSED UNIVERSITYIf you have no particular preferences and would like PRESTASI to identify a suitable institution for you, proceed to section 7.

First Choice of University

Name of University N/AComplete Address:

Faculty / Department

Have you requested admission to the university Yes NoHave you received an admission from the university *if yes, attached the Letter of Admission Yes No

Are you receiving or applying to get funding support Yes NoIf receiving, please specify the amount

Contact Person Email

Second Choice of University

Name of University N/AComplete Address:

Faculty / Department

Have you requested admission to the university Yes NoHave you received an admission from the university *if yes, attached the Letter of Admission Yes No

Are you receiving or applying to get funding support Yes NoIf receiving, please specify the amount

Contact Person Email

7. EDUCATIONAL BACKGROUNDList of universities and colleges attended. Start with the most recent one. If you are in the process of finishing your study or attended graduate program but not completed, please indicate in the below table.

a. Name of Institution UNIVERSITY OF INDONESIA (College)Degree ObtainedBACHELOR

CityDEPOKCountryINDONESIA

FacultyFACULTY OF NURSINGMajorNURSING SCIENCE

Start Date (MM/YY)End Date (MM/YY)

GPA3.07

EDUCATIONAL BACKGROUND (continued)

b. Name of Institution SMA NEGERI 2 BANDAR LAMPUNG (High School)Degree ObtainedN/A

CityBANDAR LAMPUNGCountryINDONESIA

FacultyN/AMajorSCIENCE

Start Date (MM/YY)

End Date (MM/YY)

GPAN/A

c. Name of Institution SMP NEGERI 1 TALANG PADANG (Junior High School)Degree ObtainedN/A

CityTANGGAMUSCountryINDONESIA

FacultyN/AMajorN/A

Start Date (MM/YY)

End Date (MM/YY)

GPAN/A

d. Name of Institution SD NEGERI 1 TEKAD (Elementary School)Degree ObtainedN/A


FacultyN/AMajorN/A

Start Date (MM/YY)

End Date (MM/YY)

GPAN/A

e. Name of Institution TK AISYIAH BUSTANUL ATFAL (Kindergarten)Degree ObtainedN/A


FacultyN/AMajorN/A

Start Date (MM/YY)

End Date (MM/YY)

GPAN/A

8. SCHOLARSHIP HISTORYPlease record any scholarship or fellowship that you received in the past, starting from the university level. Additional paper is allowed if necessary.

Have you ever received any scholarship or other funding support from any institution? YesNo*if no, proceed to the next section

Scholarship title N/ALevel ofEducation

Start date (DD/MM/YY) End Date (DD/MM/YY)

Scholarship ProviderContact Person(Name & Email)

Funding Full PartialType of scholarship Degree Non degree



Scholarship Provider

Contact Person(Name & Email)







Scholarship title Level ofEducation





9. EMPLOYMENT HISTORYList your work experiences since university until present. Start with the most current one. Additional paper is allowed if necessary.

a. Name of Institution FACULTY OF NURSING,UNIVERSITY OF INDONESIAPosition TitleJUNIOR LECTURER

Full Address :

UNIVERSITY OF INDONESIA RIK Area, Building E Floor 7, University of Indonesia, Depok, West Java, Indonesia, Postal Code : 16428Start date (MM / YY)02/2012

End date (MM / YY)RECENTLY

Phone(+6221) 78849120Email [email protected]

Employment category Government Institution Research Institution University / School Private Institution Media NGO Entrepreneur / Freelance Other, please state:___________________________

Responsibility :

I worked as a junior lecturer in Faculty of Nursing in the specificities of Psychiatric Nursing. Besides teaching, I was also assigned to run an internship program for 2 years as Practitioner Nurse in Marzoeki Mahdi Hospital, which is the national reference mental hospital in Indonesia. In addition, I am also active in the committee or any social activity performed by the faculty.Level of staffing: Low rank Middle rank Top management Not applicable

b. Name of Institution NUSANTARA PROFESIONAL EDUCATIONPosition TitleSENIOR HEALTH ASSOCIATE

Full Address :

Jalan Yahya Nuih No. 20 A RT 01 RW 05 Kelurahan Kemiri Muka, Kecamatan Beji, Depok, West JavaStart date (MM / YY)03/2009

End date (MM / YY)12/2013

Responsibility :

I was responsible for analyzing and designing quality seminars and training in the field of health.

10. COMMUNITY SERVICES ACTIVITIESList professional, societal or other organizations in which you now hold membership or have been active in the past. You are allowed to use additional paper if necessary.

a. Name of institutionHIMPUNAN MAHASISWA ISLAM (HMI) - CABANG DEPOK(ISLAMIC ASSOCIATION OF UNIVERSITY STUDENT - BRANCH DEPOK)

Start date (MM/YY) 09/2012Address :

Jalan Karet No.09 Rt 01 Rw 05 Kelurahan Kemiri Muka Kec. Beji Depok, West Java (16423)

End date (MM/YY)03/2014

PositionGENERAL CHAIRMAN

Responsibility :

HMI is a student and youth organizations with the aim to provide guidance of leadership for Islamic University student as the generation of future leaders in Indonesia. As General Chairman I take full responsibility of all activities conducted by the board of HMI Branch Depok. In doing leadership coaching to members I emphasized the importance of mutual respect between religious communities and upholds the human rights.

b. Name of institutionLEMBAGA KAJIAN KEPERAWATAN INDONESIA(INDONESIAN NURSING STUDIES CENTER)


HMI Cabang Depok Bulding, 2nd FloorJalan Karet No.09 Rt 01 Rw 05 Kelurahan Kemiri Muka Kec. Beji Depok, West Java, Postal Code : 16423

End date (MM/YY)Recently

PositionFOUNDER, CHIEF EXECUTIVE OFFICER

Responsibility :

Indonesian Nursing Studies Centre is a non-governmental organization that focuses on the study and research on development of nursing in Indonesia. This organizationis a non-profit. As founder and CEO then I also responsible for all activities undertaken by Indonesian Nursing Studies Centre.

COMMUNITY SERVICES ACTIVITIES (continued)

c. Name of institutionBADAN EKSEKUTIF MAHASISWA FAKULTAS ILMU KEPERAWATAN UI(STUDENTS EXCECUTIVE BOARD of FON UI)


Faculty of Nursing, University of Indonesia, Depok, West Java, Indonesia, Postal Code : 16428

End date (MM/YY)12/2009

PositionCHAIRMAN

Responsibility :

Student Executive Board is intra-campus student organizations which is an executive agency at the university or faculty level. Its primary focus is implementing various programs and activities that are divided into several areas, from advocacy to creativity. As Chairman I am responsible for the entire management of activities during the period.

11. SHORT ESSAYSPlease note that your answers should not be more than 250 words for each question. Anything over this limit will not be considered. Attach additional paper if necessary.

PERSONAL INFORMATION

a. Briefly describe your personal background and daily activities, including interaction with your family members and community.

Generally, I love being in community and organization. I was elected as chairman of the Student Executive Board (BEM) at the faculty level. As a nursing student activists, I am committed to supporting efforts to improve the quality of health care, one of them to support legalization nursing legislation in Indonesia

In addition, I am also active in the organization of the Islamic Association of University Student (HMI) Branch Depok and I was elected as chairman of HMI Branch Depok for period of 2012-2013. I am also active in the national board of Association of Indonesian Intellectuals Muslim (ICMI) as secretary of the Department of Welfare. In every organization that I follow, I emphasize the the importance of mutual respect for differences, tolerance, and uphold the human rights. I think that the Muslim, as the majority population in Indonesia, should be able to give an example of the mutual respect for differences, and uphold the human rights.

I am currently working as a lecturer at the University of Indonesia. But my passion in a variety of social activities and the organization has never receded. With the knowledge and experience of leadership and social activities, I establish a non-governmental organization called Indonesian Nursing Studies Center.

I am an outgoing person, easy to get along, and humoris. But, of course I know when I have to adjust my attitude as a leader. My leadership style tend to be democratic. Although at certain times I can make decisions in my own..

b. Briefly describe what you consider to be your strengths and weaknesses

The positive aspect that became my strength is my capacity as a leader. Various experiences of organizations and social activities both as staff and as chairman I have ever been through. But of course that does not make me stop learning. I understand that I must keep learning and practice to improve my skills and knowledge. I have a high motivation to achieve goals that I want. I still remember that to become a lecturer in University of Indonesia is not easy, but with great effort and willingness to continue learning I could finally accepted. Furthermore, I do everything by the planning that has been prepared, even though sometimes I have to deal with unexpected conditions. And for me the time is extremely valuable. Time is gold. What I believe is that the success I have achieved, one of the reason, is because I am able to become a disciplined person.

The difficulty I face is my tendency to be democratic over times, sometimes it requires a long time for me to make single decision. I have to make sure that the decisions that I took brings a lot of benefits, and minimize the conflict. But I keep learning and strive to overcome it with a lot of discussions with people who have a lot of experience in leading.

ACADEMIC AND PROFESSIONAL DEVELOPMENT

c. Briefly describe significant factors that have influenced your educational and professional development. What challenges have you overcome in pursuing your professional development? Describe the challenges as well as any insights, perspectives or skills you gained in overcoming them.

Significant factors that affect me in terms of education and professional is consciousness as a nurse, and awareness of the condition of health care in Indonesia. There must be a set of of people who have a strong intention to fight in promoting health care in this country, and why not starting with my self ?

The first challenge arises at the beginning of my education at the University. At first, being a nurse is not an ideal goal I would expect. But thanks to the encouragement and great advice from my parents, they said that I was placed in this field is certainly not without purpose. Surely there are good intentions behind all things. Eventually at that point I decided to use all my capability in promoting this profession and improve the quality of health services in Indonesia.

The second challenge I had when graduating from university. I think that to strive to the fullest, I have to be the right person, at the right time and in the right place. Currently, nursing development center still centered at the University of Indonesia, then the conclusion I must joined there. Is it that easy? of course not. However, with the genuine intention and endeavor I was successfully accepted at the University of Indonesia to continue the vision I have.

d. What is the topic that you are interested in for your future research? Please elaborate more on the mentioned topic.

For future research, I am interested in the field of Emergency Psychiatry Nursing both in the disaster area and the community.

Emergency Psychiatry Nursing becomes important in Indonesia. It is based on several arguments. First Indonesia is a disaster-prone country, but the aspect of psychiatry is not too concerned, whereas it is very necessary to prevent any sustained trauma to the disaster victims. Second, current psychiatric illness is still seen as a humiliating disease in Indonesia so that families are reluctant to take care of family members who are mentally ill. The community-based approach is very necessary for this case.

SOCIAL ACTIVITY

e. Please propose a plan on how will you share your new skills, knowledge and perceptions with your colleagues and community.

Big planning is to utilize my experience in various organizations that I follow. Almost all of these organizations have a high attention to the health sector. Even social organization such as HMI or ICMI has a special department which concentrates on health issues in Indonesia. I think by sharing knowledge, skills and new perceptions through mass organizations is an effective and efficient way.

f. If you are awarded the grant, how will you apply your newly-acquired skills and knowledge to develop your country or region and to improve your performance in your institution?

As I mentioned earlier, that Emergency Psychiatry Nursing will be divided into 2 main concern, The first is the disaster area and the second in the community.

In the disaster area I would encourage the government and private parties to pay more attention to aspects of psychiatry on disaster victims. With the knowledge and abilities which I get , I expected to make the formulation of a specialized programs for helping the disaster victims passed their traumatic. Physical assistance will be useless when the victims continue to be covered the horror of disaster they just encountered.

While in the the community, instilling an understanding that mental illness is not anything embarrassing be the primary goal. Base movement will begin from the youth in each region to then be able to build a Emergency Psychiatric Post which will provide profound information for families about mental illness and way to handle it.

VISION AND LEADERSHIP

g. Illustrate the chain of command in your current institution, which best describe the line of responsibility between you and your supervisor(s), colleagues and/or your subordinate.

HEAD OF PSYCHIATRIC NURSING DEPARTMENT DEPARTMENTDEAN OF FACULTYSUPERVISORCOLLEAGUEMY SELFCOLLEAGUE

: Line of Coordination: Line of Command

h.

Please give example(s) on how you demonstrated your leadership skills on your daily activities, whether in your current or previous employment, or within the community.

The ability to lead is certainly not just come from our self. The ability of someone in the lead also coming from recognition. I feel very grateful often trusted to be a leader in a variety of activities. Both long and short term. I am currently trusted be the Chairman of the Committee in the Selection of Best Students in the Faculty of Nursing - UI

Being a leader is different from being a boss. Being a leader requires me to listen to the aspirations of others. Being a leader means requires me to reduce me time. Being the leader requires me to look at a problem as a whole picture. Basically being a leader is how I put aside personal interests to the sake of common interest. But behind all of that, being a leader is a priceless opportunity to improve the quality of myself.

i. If you are awarded the grant, briefly explain your major concern(s) during your future study and your plan to overcome these concern(s).

My main concentration is to be able to continue my education until the doctorate level. Because for me, education is primary key in resolving various problems which occurring.

But, of course, good science is applied science. Before stepping on the doctoral level, I want to apply the knowledge which I get directly to the community in a minimum period of 3 years. I think it is ideal to prepare the basis of my doctoral education which I will take later.

j. Briefly describe your professional goals and how they are related to major problems in your country or region.

The main problem in Indonesia is located on the 3 main sectors, education, health and the environment. My main objective is to create adequate health care. This can be achieved by giving influence to the 2 main things, external and internal. The external factor is the government's policy and the second factor is a qualified health care provider. When the two main factors can be harmonized certainly adequate health care is no longer a dream.

12. REFERENCE SUMMARYPlease provide the data of your referees. The referees should not have family ties with you. This section should stay attached with the application form.

a. Title and Name

Institution Position

TelephoneEmail

How long have youknown this referee

Professional relationship to youPlease check only one box Lecturer or Professor Employer or Job Supervisor Research Advisor Other:______________________

b. Title and Name


TelephoneEmail



c. Title and Name


TelephoneEmail



By my signature below, I certify that, to the best of my knowledge and belief, the information provided in all parts of my application is accurate and complete. I understand that any false statement or the withholding of any relevant information may provide grounds for the withdrawal of any offer of appointment or, if an appointment has been accepted, for its immediate cancellation or termination. If awarded, I agree to comply with any necessary regulations made by the USAID Scholarship PRESTASI Program.

Note: If sees fit and with your consent, information contains in this application form might be shared to other scholarships program under the USAID Indonesia (please check Agree). If you decline (please check Disagree), your information will not be shared to other scholarship program outside USAID PRESTASI and this condition will not affect your selection process under USAID PRESTASI. Agree Disagree

Name & Signature of applicant _______________________________________ Date ____________________

PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II5

PRESTASI Application Form

Documents

Transcript of PRESTASI Application Form