Application Form for the Institute for Public Health Summer Research Program

APPLICATION FORM FOR THE INSTITUTE FOR PUBLIC HEALTH SUMMER RESEARCH PROGRAM

Application Instructions: Click Here Reference Evaluation Form: Click Here All application materials must be submitted by Thursday, February 1, 2018. A complete application must be submitted and sent in ONE PDF document to [email protected]. Incomplete applications or documents sent as separate files WILL NOT be considered. All Undergraduate and Post-baccalaureate students should fill out Section C: Table 4; All Graduate and Medical students should fill out Section C: Table 5. Please fill out the form using font Calibri size 11. SECTION A *Indicates a required field. Please type in grey areas. Table 1: Personal Information *First Name *Middle Initial *Last Name *Address 1 Address 2 *City *State (Only if country is U.S.) *Zip *Primary Phone (XXX-XXX-XXXX) *Evening Phone (XXX-XXX-XXXX) Other phone *Email *Date of Birth (MM/DD/YYYY) *Country of Birth *State of Birth (Only add if country is U.S.; type in abbreviated format e.g. AL) SECTION B *Indicates a required field. Please type in grey areas. Table 2: Affirmative Action *Gender *Citizenship *Race *Ethnicity *Disability *Disadvantaged Background *If you are from a disadvantaged background please describe (e.g. rural, financial, etc.)(max. 100 characters) *Military Veteran

SECTION C * Indicates a required field. Please type in the grey areas. For Undergraduate & Post-baccalaureate Students Only Table 4: Current Professional Position and Institutional Information *ACT Score *SAT Score *College *College City *College State (Only add if country is U.S.; type in abbreviated format e.g. AL) *Major Area of Study *College GPA *Graduation Date (MM/YYYY) *If you graduate by the start of the summer program, June 1, 2018, please indicate what you are planning to do next and if you have matriculated into the next degree program (e.g. MPH, MD, PhD, etc.) (max. 100 characters)

For Graduate & Medical Students Only Table 5: Current Professional Position and Institution information *Institution *School *Institution city *Institution state (Only add if country is US; type in abbreviated format e.g. AL) *Degree in progress *If you indicated ‘other’ for degree in progress, please state which one. *Are you currently enrolled in a dual degree program? *Do you currently receive scholarships, stipends, or other funding from your current program? *If you are currently enrolled in a dual degree program and/or you receive funding for your education, please describe *GPA *Graduation Date (MM/YYYY) *If you graduate by the start of the summer program, June 1, 2018, please indicate what you are planning to do next and if you have matriculated into the next degree program (e.g. MPH, MD, PhD, etc.)(max. 100 characters)

3 Section D *Indicates a required field. Please type in the grey areas. Table 6: Most Relevant Employment History *First Extracurricular Activity or Place of Employment *Years of Participation *Recognitions or Positions Held (max. 500 characters).

*Second Extracurricular Activity or Place of Employment *Years of Participation *Recognitions or Positions Held (max. 500 characters).

Third Extracurricular Activity or Place of Employment Years of Participation

4 Recognitions or Positions Held (max. 500 characters).

Table 6: Relevant Employment History Continued Fourth Extracurricular Activity or Place of Employment Years of Participation Recognitions or Positions Held (max. 500 characters).

Fifth Extracurricular Activity or Place of Employment Years of Participation Recognitions or Positions Held (max. 500 characters).

5 *Indicates a required field. Please type in the grey areas.

6 Table 7. Goals and Interest *Please list any immediate and long-term career goals you may have. Please be specific (e.g. "PhD Molecular Microbiology", "Pediatrician", "Physician", "MD/PhD", "MPH") and brief. (max. 500 characters).

List any honors, awards, or recognitions you have received (max. 500 characters).

*Are you interested in writing a research paper? If so, please explain (max. 500 characters).

7 *Are you interested in continuing research in public and/or global health beyond the duration of the summer research program? If so, please explain (max. 500 characters).

SECTION E *Indicates a required field. Table 8: Preferred Training/Research Interest Please select ONLY three choices of preferred training/research interest by clicking on the box. Aging/Geriatrics Genetics Anthropology Global Health Behavioral Science/Health Education Health Policy Biostatistics/Statistics Immunology Community Health Medicine Dissemination and Implementation Infectious Disease Engineering Pathology Environmental Science Pediatrics Epidemiology Public Health Evaluation/Research Methods Social Work

*Indicates a required field. Please type in the grey areas. Table 9: Mentors/References Please provide the names of two references and have them complete the Reference Evaluation form (https://wucrtc.az1.qualtrics.com/jfe/form/SV_6Mur6Xmh4hJxlxr). Each reference must upload a reference letter with the form. They must be a professor, work supervisor, academic advisor, or sponsor of an activity or club in which you currently participate or most recently have participated in. Both the reference letter and evaluation form must be submitted by the reference to be considered an applicant. First Reference *Relationship to Applicant *Last Name *First Name *Middle Initial 8 *Degree (PhD, MD, etc.) *Position *Organization *Department *Phone (XXX-XXX-XXXX) *Email Second Reference *Relationship to Applicant *Last Name *First Name *Middle Initial *Degree (PhD, MD, etc.) *Position *Organization *Department *Phone (XXX-XXX-XXXX) *Email

9 *Indicates a required field. Please type in the grey areas. Table 10: Emergency Contacts Emergency Contact 1 *Last Name *First Name *Relationship *Street Address 1 Street Address 2 *City *State (Only add if country is US; type abbreviated format e.g. AL) *Zip Code *Primary Phone (XXX-XXX-XXXX) *Evening Phone (XXX-XXX-XXXX) Other Phone Emergency Contact 2 Last Name First Name Relationship Street Address 1 Street Address 2 City State (Only add if country is US; type in abbreviated format e.g. AL) Zip Code Primary Phone (XXX-XXX-XXXX) Evening Phone (XXX-XXX-XXXX) Other Phone

Table 11: Health Insurance *The $2,000 stipend/month will be paid on June 30th, 2018 and July 31st, 2018. Are you able to pay for your own accommodation, consumables, health insurance, and if you select an international project also pay for the visa, HTH worldwide insurance, vaccines, medication, etc. until you receive your first payment on June 30th, 2018? *Do you have comprehensive accident and health insurance?

Table 12: Additional Information *How did you hear about the programs? If you selected other, please indicate where you heard about the programs. If someone told you about the program we would appreciate learning their name (max. 100 characters).