Yale/StanfordJohnson & Johnson Global Health Scholars Program

Application for Career Physicians for 2018-2019 Program Year

Instructions

Please type in the shaded areas. All documents must be received(via mail) by Friday, December 8, 2017.

You will need to submit the following:

  • this completed application
  • a current CV
  • two letters of recommendation from supervisor physician and physician
  • a passport-type photo.

Please mail all these items, in one package to:

Laura Crawford, MPH Program Administrator

Yale/Stanford J&J Global Health Scholars Program

Yale School of Medicine, FMP 101

333 Cedar Street, PO Box 208030

New Haven CT 06520-8030

Please note that, if selected, you are strongly encouraged to attend the Pre-Departure Orientation in New Haven on Friday, May 25, 2018.

Personal Information

Name

Address

City, State, Zip

Cell Phone

Country of Citizenship

Institutional Email

Alternative Email

Background/Experience

Institution/Employer:

Current Academic/Practice Title:

Board Certification(s) in:

Certification dates:

Year training completed:

Languages spoken fluently:

Have you had prior global health experiences?Yes No

If yes, where was this experience, when was it, how long did it last, and what role did you play? What do you hope to gain through our program and how do you think this will impact your career plans? Please note that there is no space limit to this response, so elaborate!

If no, please share what you hope to gain through our program and how you think this will impact your career plans.Please note that there is no space limit to this response, so elaborate!

Flexibility and cultural sensitivity are critical for a successful global health experience. Please describe a time when you have demonstrated flexibility in the face of an unexpected professional setback. Please note that there is no space limit to this response, so elaborate!

Please comment on how this rotation would inform your current practice and/or academic activities. Please note that there is no space limit to this response, so elaborate!

Rotation

Please list the dates in the coming academic year during which you would be unable to participate in a six week rotation:

Please list the site(s) and the six week blocks in which you are most interested.

First choice site:

Second choice site:

Third choice site:

I could be away the following dates:

We will try to accommodate your site selection. If you have specific reasons for choosing a site/date, please state them:

Accomodations are often tight at our sites; please let us know if you would like to travel with family members or if you have other special needs.

If you have any questions about the application, please contact Laura Crawford at .

Deadline is December 8, 2017