APPLICATION FORM

Full Name (exactly as it

appears on your Salwiyadi N/A N/A
passport):
Gender: Male
Date of Birth 03-14-1988
Country of Birth: Indonesia
Country of Residence: Indonesia
Country of Citizenship: Indonesia
Passport Number B 2409029
Date of Passport Issue 01-15-2016
Passport Expiry Date 01-15-2021
Place of Issue Meulaboh
Address Street Address: Komplek Hadrah 3 No.E8.
Desa Lampeudaya. Kec. Darussalam.
Kab.Aceh Besar. Prov.Aceh
City: Banda Aceh
State / Province: Aceh
Postal / Zip Code: 23374
Country: Indonesia
Telephone Number (+62) (811) 6814388
Email: salwiyaditheleader@gmail.com
Emergency Contact
Fathun
Name:
Emergency Contact
Colleague
Relationship:
Emergency Contact
(+62) (811) 6889822
Phone:
Emergency Contact
hellofathun@gmail.com
Email:
Dietary Considerations:
Please state if you have Halal
any restrictions.
YSEALI Member: Yes
Educational Background: Institution Degree From To
Degree
Institution Name Received
(begin with most recent) Location Name (MM/YY) (MM/YY)
(Y/N)
 dr. Zainoel Banda Resident
Abidin Hospital Aceh, Internal July 2016 present Internist
Banda Aceh Aceh Medicine
Medical Faculty Banda
February Medical
of Syiah Kuala Aceh, Medicine July 2005
2012 Doctor
University Aceh
Senior
SMA Negeri 8 Banda August April High
High
Banda Aceh Aceh 2002 2005 School
School
MTs Junior
Aceh August June High
Muhammadiyah High
Selatan 1999 2002 School
Meukek School

Work Experience: From To

Position (Please Location
specify if position Institution (City,
(MM/YY) (MM/YY)
is part-time) Country)
General
Meukek Primary Aceh
Practitioner /
08/2013 present Health Care Selatan,
Medical Doctor
(Puskesmas) Indonesia
(Full time)
Founder and Aceh
JJ's Clinic
01/2013 present Director (part- Selatan,
Meukek
time) Indonesia
Co Founder and
The Leader, Banda
Secretary (part-
12/2012 present Youth-Led Aceh,
time and
Organization Indonesia
voluntary)
World Health Day Banda
Moderator (part
04/2013 04/2013 2013 : Update on Aceh,
time)
Hypertension Indonesia

Volunteer work, Type of Event/Institution Name

Your Role
From To
activity (Location) (MM/YY) (MM/YY)
Internships, and Extra-
Pertemuan Ilmiah
Curricular Activities: Tahunan PERNEFRI
(begin with the most 2018: “improving the
Forum quality of hypertension, Committee 10/2018 10/2018
recent; only include kidney disease and
dialysis management,
activities you have Banda Aceh-Indonesia
participated in the last 3 Konferensi Kerja
years) Nasional PPHI-PGI- Participant
PEGI 2018 in and
Conference conjunction with Aceh 1st Winner 07/2018 07/2018
Gastroenterohepatologi of Daldiono
Update 2018 in Banda Award
Aceh
Kongres Nasional
Perhimpunan Dokter
Spesialis Penyakit Participant
Forum Dalam Indonesia Poster 07/2018 07/2018
(KOPAPDI) in Solo Presentation
Central Java,
Indonesia
The 9th Endocrinology
& Diabetes Forum of
Sumatera Region in
conjunction with The
Forum and
2nd Aceh Committee 03/2017 03/2017
Conference
Endocrinology &
Diabetes Update
(AEDU) in Banda
Aceh, Indonesia
Experience with the U.S. Location
From To
(Institution, Type of Activity and Your Role
Embassy or U.S. City)
(MM/YY) (MM/YY)

Consulate General Committee and Facilitator of Youth

(including but not limited Coalition for Sustainable Peace:
Sustaining Peace from Schools to
to: U.S. Government Banda
Communities, in Aceh, Maluku, 09/2017 09/2018
Aceh, Aceh
Central Sulawesi, North Maluku,
Exchange Programs; and South Sulawesi, supported by
U.S. Mission activities; the U.S Embassy in Jakarta
YSEALI activities; etc.):

Active Memberships Associations, Organizations, etc

Co Founder and Secretary at The Leader, Youth-Led Organization
Indonesian Medical Doctor Association
Asian Medical Students’ Association (AMSA) of Syiah Kuala University
Yayasan Bina Antarbudaya, a partner of AFS Intercultural Learning Inc.

English Proficiency: Reading Writing Speaking

(please check) Beginner - - -
Conversationalist - - -

Fluent

Why are you an ideal I would like to address my reasons I am as an

candidate for the 2019 ideal candidate for the 2019 YSEALI –
YSEALI – ENGAGE ENGAGE Workshop and what I hope to gain
workshop? from this workshop into two parts. Firstly, I have
been working in the field of public health and
non communicable disease since I was in
medical school. It was through my participation
in the 29th Asian Medical Students’ Conference
(AMSC) 2008 “Non Communicable Disease
and Health Promotion” in Tokyo, Japan. Topics
that were delivered had helped me understand
NCDs as the major health treat that must be
overcome in Asia today. This conference, along
with my studies on medicine and general public
health, triggered me to become an Internist.
Secondly, I believe in this workshop I will meet
young leaders with medical skills and public
health interest from different country; this would
be an opportunity to create and develop
professional connections among ASEAN Youth.
I will have the opportunity to learn from
professional expert who are world leaders in
their fields. This workshop is an opportunity for
me to advance my personal and professional
skills and competencies to grow, scale and take
the project I have been working to next level.
What prior experience Currently I am resident of Internal Medicine at
do you have in working dr. Zainoel Abidin Hospital in Banda Aceh,
at the community level before that I was a medical doctor in Aceh
(within a particular selatan Primary Health Care for 3 years. Aware
setting such as a of Increasing death and disability rates due to
neighborhood, NCDs (i.e diabetes, cardiovascular diseases,
school/college/university, chronic respiratory diseases, cancers and
workplace) to help mental disorders) can be seen worldwide, I
prevent and/or combat implemented a home visit program. This routine
non-communicable program aimed to control patients with diabetes
diseases and/or mental and cardiovascular diseases where I checked
health conditions? blood pressure and blood glucose, it was free
for patients with low economic backgrounds.
For this effort, in 2015 I have been selected as
1st winner of the Best General Practitioner
(Dokter Teladan) of Aceh Selatan.
Within my organization The Leader, in 2014 we
started a project called The Aceh Global Health
Youth Forum. The forum conducted, a one day
workshop and created a community work
program to raise awareness about health
promotion, prevention and curative actions.
Recently, in 14th November 2018, I initiated a
World Diabetes Day 2018 in Banda Aceh for
diabetes awareness campaigns where we open
a booth in city park of Banda Aceh, conducted
blood glucose check and we share information
about the warning signs of diabetes.
Category: (check all A new/existing idea that seeks tochange public
those applicable) policy or public discourse on public health
issues
Overall Goal: (50 words) The Aceh NCDs Forum is to raise the
awareness of Non Communicable Disease and
health problem mapping and alternatives
solving in Banda Aceh.
Idea: (250 words) The Aceh NCDs Forum will be conduct as one
day workshop and as community work among
inter health sectors students to introduce NCDs
problem in Banda Aceh. It tends to map the
health problems in the community, find
alternative solution, take real action to
collaborate and solve the problem through
community work. Furthermore, it would shape
the students attitude to have the health working
atmosphere. The goal is to generate new health
 agents among health sector students in Aceh to
raise awareness of Non Communicable
Disease by having real inspiration from leaders
and within the field experiential learning. This
would meet the purpose to build the health
leaders network. Participants are welcome from
students across public and private university in
Banda Aceh. Those expected come from the
field of medicine, public health, nursing, dentist,
midwife, pharmacist, psychology, and other
health enthusiast in the field. Targeted number:
20 participants for the forum and community
project. The health problem assessment prior
having the recent data assessment of the
community health problem. Primary data
collection from stakeholders, we will visit
government stakeholders to have data
collection about their programs in Banda Aceh,
include prior programs and future plan, mostly
about health issues including NCDs.
Resources Needed: (50 10 team (in collaboration of The Leader, Asian
words) Medical Students’ Association (AMSA), YSEALI
Alumni and PT. Nutrifood Indonesia) and
financial resources around Rp 5.000.000 to Rp
10.000.000 for accomodation, meals and
community project.
Timeline: (50 words) The project will be conduct on 1-2 June 2019
Outcomes: (150 words) 1. Raising awareness of Non Communicable
Disease and inter health sectors working
attitude
2. Health problem mapping and alternatives
solving in Banda Aceh.
3. Establish health community network within
the students in Aceh.
4. Health project initiatives related to non
communicable disease.
Upload Photo One Forum.JPG
Photo Caption One One day workshop for participants tends to
map the health problems related to NCDs in the
community and find alternative solution.
Upload Photo Two Community Work.JPG
Photo Caption Two Participants will take real action to collaborate
and solve the problem through community work
Upload Photo Three Campaign Awareness NCDs.JPG
Photo Caption Three Campaign awareness in community work about
the warning signs of diabetes and
cardiovascular diseases
I declare that the
information supplied in
this form is true to the Yes
best of my knowledge
and belief.
Signature
Date 01-14-2019