Business Credit Application s1

3BUPMC International Training Center of Excellence INTERNATIONAL HEALTH CARE MANAGEMENT PROGRAM APPLICATION

PERSONAL INFORMATION Last Name: First Name: Name in Native Language/Alphabet: Phone: E-mail: Address: City: State: ZIP Code: Country: Date of Birth: Gender: Male Female Passport Number and Issuing Country: Languages Spoken: Will you require an interpreter? Yes No Dietary Restrictions: PROFESSIONAL INFORMATION Hospital/University Name: Medical Specialties (if applicable): Degrees: Other Certifications: How long have you been working in your specialty area (years)? Administrative Positions Held:

Contracting Organization Name and Address (in the case of an agreement, please list the full legal name of the person or entity with whom UPMC would be doing business):

Address: PROFESSIONAL DEVELOPMENT Briefly describe your professional development goals for the International Health Care Management Program:

Please describe what types of shadowing/observation opportunities you would like to experience:

Please return this application along with a copy of your current curriculum vitae to Juli Kundu at [email protected] 1 2B3BUPMC International Training Center of Excellence INTERNATIONAL HEALTH CARE MANAGEMENT PROGRAM APPLICATION

ELECTIVE WORKSHOP CHOICES PLEASE CHECK ALL WORKSHOPS OF INTEREST Quality Operations and Strategic Planning Joint Commission International: Approaches to Success IDFS (Integrated Delivery and Finance System) Model Quality Data Planning, Collection, and Audit Outpatient Clinic Operations Infection Control Facility Design/Logistics Quality Excellence through New Models of Clinical Pathway Development Accountability (Just Culture) System Capacity Management Cost Efficient Procurement Strategy New Product and Process Development: From Idea to Patient Experience (Quality vs. Quantity) Introduction Performance Improvement Process Community Health Assessment and Planning Precision Medicine Models of Care Management Service Line Development Leadership Finance, IT/Electronic Medical Record How to be a Good Leader and a Good Follower Managing Financial Statements: From Accounting to Operations Communicating Across the Organization Budget Creation and Variance Analysis Emotional Intelligence Project and Capital Expenditure Valuation (ROI) Change Management/Implementing Sustainable Interoperability and Systems Design Change Negotiation and Conflict Resolution Structured Clinical Notes Practicing Evidence-Based Management in Health Care Utilizing Technology for Community Outreach Settings (Telemedicine) Effective Trainee Teaching and Management Big Data/Healthcare Analytics Employee Engagement Strategies What Makes a Good Physician Leader? (Required) Performance Management Please describe any additional workshop topics you may be interested in:

Additional Comments:

Shirt Size:

Please return this application along with a copy of your current curriculum vitae to Juli Kundu at [email protected] 2