Primary Care Physician Scientist Program

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Division of General Internal Medicine Hospital of the University of Pennsylvania Philadelphia, PA

Application for the Penn Primary Care Research Training Program Hospital of the University of Pennsylvania Application for the Penn Primary Care Research Training Program Application Instructions

Please note: We have a rolling admissions policy with the final application deadline being November 30, 2016 for admission in July 2017. (Applications may be accepted after this date, but consideration for funding requires a timely application submission). Classes for the Program start on July 1, 2017. 1) Please fill out the application in its entirety. Do not put “refer to CV” for any of the information requested. 2) In addition to the application, we request the following information be submitted to the address below. Electronic submissions are prefered: a. Personal Statement a.i. Please discuss your clinical background, research interests, and reasons for pursuing the Fellowship. b. Curriculum Vitae c. 3 Recommendations d. MCAT or GRE report e. Official, Sealed Transcripts from All Relevant Undergraduate and Graduate Institutions. f. Picture of Yourself (optional) 3) The reference form should be sent electronically to the three people who will be writing recommendation letters on your behalf. They should: a. Fill out the form and write a letter. b. Sign the form and the accompanying letter. c. The signed form and letter can be sent electronically, faxed, or mailed to the address below. 4) Your application will be reviewed when the application and all supporting documents have been received. 5) If you have any questions, contact Sade Paige (Division Administrative Coordinator), Marilyn M. Schapira, GIM Fellowship Director, or Rachel M. Werner, Director, Penn Primary Care Research Training Program c/o Sade Paige Division of GIM Administrative Coordinator University of Pennsylvania 1218 Blockley Hall 423 Guardian Drive Philadelphia, PA, 19104 Tel 215 573-5536 Fax 215 898-9924

Marilyn M. Schapira, MD, MPH Professor of Medicine, General Internal Medicine Director, GIM Fellowship Program Phone: 215 898 2022 Email: [email protected]

Rachel M. Werner, MD, PhD Professor of Medicine, General Internal Medicine Director Penn Primary Care Research Training Program Email: [email protected]

of 8 Page 3 of 8 Academic Program of Interest and GIM Fellowship Option

1. Please check the box indicating what academic degree you are interested in applying to as part of the GIM Fellowship program. More information about the programs can be found on the websites.

Masters of Science in Health Policy ______http://www.med.upenn.edu/mshp/

Masters of Science in Clinical Epidemiology ______http://www.med.upenn.edu/cceb/epi/edu/msce/

Unsure, would like to discuss with fellowship director ______

2. Please check the box below if you are trained in Internal Medicine and would like to join the Penn Primary Care Research training program as a General Internal Medicine Fellow

Yes, I would like to apply to the program as a GIM Fellow ______

Personal Information First Name: Last Name: Date of Birth: Address: Phone Numbers:

Email: Citizenship: If not a US citizen, are you a Permanent Resident?

Please indicate your current Penn affiliation: Other (if not in list): (if you answered “Not Affiliated”, please skip to Application Details below) Penn Affiliation Title:

Department: Location:

Department Business Administrator: BA Phone:

Application Details Year of Desired Enrollment: 2017

of 8 Educational Background

Please list all higher education schools attended in chronological order (do not enter “refer to cv”) Dates Graduation Institution/Location Attended Degree Major Date GPA

Test Scores: A GRE or MCAT score is required for consideration in the program. If you have not completed either for these tests, you must request a waiver from the requirement. The waiver request must include justification for why you think you should not have to take the GRE or MCAT. The waiver request must either precede or accompany this application.

GRE Date taken: Verbal V% Quantitative Q% Analytical A%

MCAT Date taken: Verbal Physical. Science Writing Biology

Post Graduate Experience

Training: Please list any post-graduate training including internships, residency, fellowships and other appointments

Title Institution/Location Specialty Dates

Work Experience

Research Positions: Please include all relevant research experiences (whether laboratory based or clinical) and health policy experiences (full or part-time)

Position Institution (name and location) Dates

Academic Honors and Honorary Societies

Title Date

of 8 Board Certification Status

Are you board eligible?

Board : Have you taken the exam? Date of Certification:

References

Please list the names, titles, and institutions of three individuals who have known you professionally whom you have asked to send provide reference letters. One should be the Director of your current program.

Name: Title:

Institution: Phone: Email:

Name: Title:

Institution: Phone: Email:

Name: Title:

Institution: Phone: Email: Experience Demographic Data

The University of Pennsylvania seeks to draw students from diverse backgrounds. The information requested below will be used to evaluate the effectiveness of our recruitment efforts and to facilitate selection of a diverse student body. This information is COMPLETELY CONFIDENTIAL. Answering these questions will NOT influence the University’s decision on admission. 1. Are you Hispanic or Latino? No Yes, Hispanic or Latino (including Spain) If yes, please check all that apply below: Which best describes your background?

Central America South America (excluding Brazil) Cuba Spain

Mexico Other ______Puerto Rico 2. Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

American Indian or Alaska Native (including all Original Peoples of the Americas) Which best describes your background? Alaska Native Navajo Chippewa Sioux

Choctaw Other ______Cherokee

Are you enrolled? No Yes, please enter tribal enrollment number ______Asian (including Indian subcontinent and Philippines) Which best describes your background? China Philippines India Vietnam

Japan Other East Asia ______Korea Other Indian Subcontinent ______Pakistan Other Southeast Asia ______Black or African American (including Africa and Caribbean) Which best describes your background? Page 6 of 8 U.S. / African American Caribbean

Africa Other ______Native Hawaiian or Other Pacific Islander (Original Peoples) Which best describes your background? Guam Samoa

Hawaii Other Pacific Islands (excluding Philippines) _____ White (including Middle Eastern) Which best describes your background? Europe Other ______Middle East

3. Do you come from a family with an annual income below established low-income thresholds? Low income Thresholds can be found at: http://aspe.hhs.gov/poverty/13poverty.cfm. Yes No Prefer not to answer

4. Are you the first generation in your family to attend college? Yes No Prefer not to answer

5. Have you attended a historically black college or university (HBCU) Yes No Prefer not to answer

6. Do you come from a rural background?

Yes No Prefer not to answer

7. Are you a Veteran? Yes No Prefer not to answer

Academic Integrity/Mandatory Question

1. Have you ever been placed on probation, dismissed or suspended from any college or university for reasons pertaining to academic integrity? Yes No

(If yes, your Personal Statement should include any facts that you believe bear on the significance of this circumstance.)

Prior Conviction If you have ever been convicted of, or pled guilty, or no contests, to any felony or misdemeanor (excluding minor traffic violations) follow this secure link: https://medley.isc-seo.upenn.edu/gradAdmissions/jsp/fast.do?fastStart=priorConvictions and provide further information on a confidential basis. In the field titled “School/program to which you are applying,” select Biomedical Graduate Studies.

Additional Documentation Required

By checking this box, you are attesting to the accuracy and validity of the information provided in this application. The application will not be accepted without a check mark in this box. Any falsified information will result in immediate disqualification for consideration for admission or withdrawal from the program if admission has already occurred.

of 8 The University of Pennsylvania values diversity and seeks talented students, faculty and staff from diverse backgrounds. The University of Pennsylvania does not discriminate on the basis of race, color, sex, sexual orientation, gender identity, religion, creed, national or ethnic origin, citizenship status, age, disability, veteran status or any other legally protected class status in the administration of its admissions, financial aid, educational or athletic programs, or other University-administered programs or in its employment practices. Questions or complaints regarding this policy should be directed to the Executive Director of the Office of Affirmative Action and Equal Opportunity Programs, Sansom Place East, 3600 Chestnut Street, Suite 228, Philadelphia, PA 19104-6106; or (215) 898-6993 (Voice) or (215) 898-7803 (TDD). Specific questions concerning the accommodation of students with disabilities should be directed to the Office of Student Disabilities Services located at the Learning Resources Center, 3820 Locust Walk, Harnwell College House, Suite 110, 215.573.9235 (voice) or 215.746.6320 (TDD).

Federal law, the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, requires all institutions of higher education to provide information on their security policies and procedures and specific statistics for criminal incidents and arrests on campus to students and employees, and to make the information and statistics available to prospective students and employees upon request. The Pennsylvania Uniform Crime Reporting Act requires Penn to provide information about its security policies and procedures to students, employees and applicants; to provide crime statistics to students and employees, and to make those statistics available to applicants and prospective employees upon request. The information about Penn is available at: http://www.publicsafety.upenn.edu/wp- content/uploads/2015/01/2014_ASR_FINAL.pdf or by calling the Division of Public Safety at (215) 898-4481.