HMS Fellowship in Patient Safety and Quality
Application Form for Positions beginning July 1, 2015
U.S. Candidates only
Personal Data
Name (first, middle, last): ______
Preferred mailing address: ______
______
Telephone: ______Fax: ______
E-mail: ______
Professional Degree: ______
Are you a citizen of the United States, a non-citizen U.S. national or permanent resident (I-551 or I-151)? Yes___ No___
If you are a graduate of a foreign medical school (except Canada), you are required to be certified by the Educational Council for Foreign Medical Graduates. If you are certified, indicate below:
Standard Certificate Number: ______
A copy must be sent with this application.
Date of passing ECFMG exam: ______
Current position and Institution: ______
______
______
______
EDUCATION, LICENSURE, AND EXPERIENCE
(Please list all educational, clinical and research appointments, beginning with your college education. Please explain any gaps using a separate sheet if necessary.)
From (month/year) / To(month/year) / Institution / Position or degree earned
Research and Career Plans
Do you plan to take a subspecialty fellowship in the future?
Yes No
Do you plan to earn any other degrees in the future?
Yes No If yes, please specify: ______
______
Do you currently have a preference for an institution at which you would be based for fellowship? Yes No
If yes: Rank all that you would accept
(1 = highest, 6 = lowest)
Beth-Israel Deaconess Medical Center __
Brigham and Women’s Hospital __
Boston Children’s Hospital __
Dana-Farber Cancer Institute __
Massachusetts General Hospital __
BACKGROUND INFORMATION
Have your privileges at any hospital or other facility ever been denied, limited, suspended, revoked, or not renewed? And/or have you ever been denied membership or renewal therein or been subjected to disciplinary proceedings in any hospital or medical organization?
Yes No If yes, please give full details on a separate sheet.
Has your license to practice medicine in any jurisdiction ever been limited, suspended, or revoked?
Yes No If yes, please give full details on a separate sheet.
Have you ever voluntarily relinquished your license?
Yes No If yes, please give full details on a separate sheet.
Please tell us how you heard about the fellowship program (check all that apply):
Fellowship website (http://www.hms.harvard.edu/hfpsq)
Advertisement in journal (please specify): ______
Advisor/Program Director (please specify): ______
Friend/associate (please specify): ______
Other (please specify): ______
PLEASE ENCLOSE:
1. Curriculum vitae
2. Personal statement of no more than three pages explaining your career goals, how the fellowship program would further these goals, along with any additional information that may be helpful to the Selection Committee.
Please ask 3 persons to send recommendation letters directly to the Admissions Committee at the street or e-mail address below. One letter must be from your current Program Director or Supervisor. Please list their names, positions, institutions, address, telephone and email here:
1. ______
______
Tel:______Email:______
2. ______
______
Tel:______Email:______
3. ______
______
Tel:______Email:______
SIGNATURE: ______DATE: ______
Application Deadline for U.S. Candidates Only: 10/10/14 for July 2015 entry.
Send completed application form with attached self-identification form, CV, and personal statement to street or e-mail address below. Please have your medical school forward transcripts directly to address below.
Grace Bommarito
Administrative Manager,
HMS Fellowship in Patient Safety & Quality
Partners HealthCare System
115 4th Avenue
Needham, MA 02494
781-433-3764/phone
781-433-3604/fax
Attachment (self-identification form for completion/submission)
HMS FELLOWSHIP IN QUALITY AND SAFETY
SELF-IDENTIFICATION FORM
Harvard University has adopted affirmative action programs to provide full employment opportunities for qualified women and minorities, qualified disabled persons, and qualified disabled veterans and veterans of the Vietnam Era. We invite you to inform us if you are a member of a protected class, if you have a disability, or if you are a Vietnam Era or disabled veteran. This information is voluntary and providing or refusing it will NOT subject you to any adverse treatment. Please answer each section by checking the appropriate response.
Self-Identification
For Affirmative Action purposes, Harvard is required by law to keep track of the race, ethnicity and sex of all applicants. We invite you to assist us in keeping accurate records by self-disclosing your race, ethnicity and sex. This information is completely voluntary and will not be kept in your personnel file.
Male Female
Ethnic Categories (please check one):
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino
Racial Categories:
American Indian or Alaskan Native: A person having origins in any of the original peoples of North, Central or South America, and who maintains tribal affiliation or community attachment.
Asian, not underrepresented: A person having origins in any of the any of the Asian subpopulations not considered underrepresented in the health professions include Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai.
Asian, underrepresented: A person having origins in any of the Asian subpopulations considered underrepresented in the health professions include any Asian OTHER THAN Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai. (i.e., Cambodian, Vietnamese, Malaysian)
Black or African-American: A person having origins in any of the black racial groups of Africa.
Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Self-Identification for Vietnam Era Veterans
In accordance with the Vietnam Era Veterans Readjustment Assistance Act of 1974 (38.U.S.C. 2012), and its implementing regulations (41 C.F.R. 60-250), the provision of this information is on a voluntary basis and will be maintained in a separate location for affirmative action program use and will not be included in the personnel file of any employee or applicant for employment.
DEFINITION: VIETNAM VETERAN
A Vietnam Era Veteran is defined as one who served on active duty for more than 180 days, any part of which duty occurred during the period between August 5, 1964 and May 7, 1975, and who received other than a dishonorable discharge as defined in the regulations implementing the Vietnam Era Veterans Readjustment Assistance Act of 1974.
Please indicate if you are a:
Disabled Vietnam Era Veteran Vietnam Era Veteran Neither
Self-Identification for Persons with Disabilities
In accordance with Sections 503 and 504 of the Rehabilitation Act of 1973, the provision of this information is on a voluntary basis and will be maintained in a separate location for affirmative action program use and will not be included in the personnel file of any employee for employment.
DEFINITION: DISABILITY STATUS
The following are examples of some, but not all, disabilities which may be included: AIDS, asthma, arthritis, color or visual blindness, cancer, cerebral palsy, deafness or hearing impairment, diabetes, epilepsy, HIV, heart disease, hypertension, learning disabilities, mental or emotional illnesses, multiple sclerosis, muscular dystrophy, orthopedic, speech or visual impairments, or any other physical or mental impairment which substantially limits one or more of your major life activities. Please indicate if you are:
Disabled Not disabled
Self-Identification for Persons from Disadvantaged Backgrounds
We are required to report the number of individuals applying to, admitted to, and graduated from our program who meet federal definitions for coming from “disadvantaged backgrounds” or “medically underserved communities.” The provision of this information is voluntary and will not be included in the personnel file of any employee for employment.
The definition of “Disadvantaged” is that which is currently in use for health professions programs (42 CFR 57.1804 (c)) and includes both economic and educational factors that are barriers to an individual’s participation in a health professions program. This means an individual who:
(a) comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; or
(b) comes from a family with an annual income below a level based on low-income thresholds according to family size, published by the U.S. Bureau of the Census, and adjusted annually for changes in the Consumer Price Index, and by the Secretary for use in health professions programs.
“Medically Underserved community” means an urban or rural population without adequate health care services. If you are unsure about whether your community qualifies, we can use the following geographic information to make that determination:
State:
County:
City / Town:
Please indicate if you believe you are from a:
Disadvantaged Background: Yes No Unsure
or Medically Underserved Community: Yes No Unsure
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