Centers for Disease Control and Prevention National Center for Environmental Health Environmental Public Health Leadership Institute Application Applicant and Program Commitments

Applicant’s Name: Last First

Applicant’s Commitment I, the applicant, understand that the EPHLI program involves a year-long commitment, and I am willing and able to make the following commitments if I am selected to participate. [Note: the program session schedule for the class of 2011–2012 is on page 2 of this form.] 1. I will devote the time necessary to participate in the institute’s activities. 2. I will be an active contributor during program sessions. 3. I will prepare for the program activities by reading materials sent in advance. 4. I will actively participate in scheduled onsite and distance-learning programs or sessions conducted during the year by telephone conferencing, computer networking and e-mail, or satellite downlinks. 5. I will plan and implement a learning project during the year. 6. If asked to do so in the future, I will consider becoming an EPHLI mentor. 7. I have daily access to a telephone and a computer with Internet access and e-mail. I will use these to accomplish institute requirements.

I have reviewed and completed the EPHLI application and agree to the commitments for participation stated on this form:

______Applicant’s Signature Date

Supervisor’s Contact Information Please provide the information requested about your supervisor.

Supervisor’s Name: ______

Title: ______Degree and/or Credentials: ______

Mailing Address: ______

City, State, and Zip Code: ______

Office Phone: ______Fax: ______

E-mail: ______

7th EPHLI Cohort—Class of 2011–2012 Applicant and Program Commitments, Page 1 of 2 Centers for Disease Control and Prevention National Center for Environmental Health Environmental Public Health Leadership Institute Application

Supervisor’s Support Statement I have read the Applicant and Program Commitments form and I agree to permit ______[applicant’s name] to take time from regularly assigned duties to participate in all sessions of the year-long Environmental Public Health Leadership Institute (EPHLI).

The program session schedule for the class of 2011–2012 is at the bottom of this page. To reduce travel cost and time away from the work site, institute sessions and material will also be delivered via distance-learning methods such as telephone conferencing, computer networking, satellite downlinks, and other means. These sessions will be open to all team members assisting in the development and implementation of the project as well as other department staff interested in learning more about the topics covered by the institute.

I, ______, [supervisor’s name] support the applicant’s participation in EPHLI. I have discussed this leadership training opportunity with appropriate organization/agency managers. We have agreed to actively support the applicant’s learning experience and project activities if he or she is selected to participate in the program. We understand that the EPHLI project may require collaboration with existing staff and the development of new partnerships. Management agrees to support these efforts and assist in developing a team approach to environmental public health problem solving.

______Supervisor’s Signature Date

Program Costs The Environmental Public Health Leadership Institute (EPHLI) will pay all allowable expenses including books and course material and approved travel and per diem costs associated with the participation in EPHLI.

Tentative Program Session Schedule, Class of 2011–2012  February 28-March 4, 2011 (CDC, Atlanta: attend presentations and graduation of previous class and participate in first session for incoming class)  October 17–21, 2011 (St. Louis, MO)  February 27–March 2, 2012 (CDC, Atlanta: presentations and graduation)

Visit the EPHLI Web site for instructions on submitting your completed application package (http://www.cdc.gov/nceh/ehs/EPHLI/application.htm).

7th EPHLI Cohort—Class of 2011–2012 Applicant and Program Commitments, Page 2 of 2