University of California San Francisco
School of Nursing
Madison Clinic Peggy Huang Diabetes Nurse Fellowship
Diabetes Trainee/Diabetes Minor Application
2015-16 Application Form
You are not eligible for the diabetes minor if you are involved in another minor or focus (HIV, Global Health, Palliative Care, etc.).
Only those students entering their second (final) year of regular Masters study are eligible to apply.
Full Name:
Current Address:
Permanent Address (if different from above):
Telephone Numbers
Home:
Mobile:
UCSF Email Address:
Education and Work Experience
Academic institutions attended (include dates):
PLEASE ATTACH YOUR CV FOR THIS PORTION
Specific diabetes coursework completed (include locations and dates):
PLEASE ATTACH YOUR CV FOR THIS PORTION
Work experience with people with diabetes:
PLEASE ATTACH YOUR CV FOR THIS PORTION
Volunteer experience with people with diabetes:
PLEASE ATTACH YOUR CV FOR THIS PORTION
Research experience involving diabetes:
PLEASE ATTACH YOUR CV FOR THIS PORTION
Demographic Information
Racial, cultural or ethnic background of applicant:______
Do you fluently speak another language? ☐No ☐Yes
If yes, what language? ______
In your estimation, do you NOW or have you EVER lived in a medically underserved community?
☐No ☐YesIfYes, where?______
Please note that “medically underserved community” refers to an urban or rural area or populations groups that lack adequate health care services. This question is aimed at ascertaining the environment in which you grew up or in which you have lived, ASOPPOSED TO THE SETTING IN WHICH YOU MAY WORK.
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Do you consider yourself to have come from a disadvantaged background (see definition below)?
☐No ☐YesIfYes, pleaseexplain:______
Please note that the definition of “disadvantaged background” includes both economic and educational factors that are or were barriers to an individual’s participation in a health professions program. Specifically, it refers to 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/training in an allied health profession; and/or
b) comes from a family with an annual income below a level based on low incomes thresholds according to family size, published by the US Bureau of the Census, and adjusted annually for changes in the Consumer Price Index.
Goals and Objectives
Please attach a one page Goal Statement to this application, outlining your interest in the Diabetes Minor and the Madison Clinic Peggy Huang Diabetes Nurse Fellows Program. Pleasebesure to discuss any relevant past work with underserved populations and any future plans tocontinue to serve this population. Include future goals and interests relevant to this course ofstudy.
Letter of Reference
Please submit one Letter of Reference ONLY if you are applying for the funding option below. Ideally, the letters will be from: 1) the person(s) who supervised your work ina diabetes-related field 2) a faculty member or advisor 3) a work/volunteer supervisor; and/or 4)apeer.
Funding Request
☐ I am applying for diabetes minor only (no clinical hours, 3 courses)
☐ I am applying for the traineeship (Minimum 40 hours diabetes clinical, 3 courses) but
no funding
☐ I am applying for the diabetes fellowship (Minimum of 80 hrs diabetes-focused clinical; 3courses and funding)
Please return the completed application and goal statement by April 30, 2015.
Maureen McGrath, PNP-BC, BC-ADM
University of California, San Francisco, Box 0606
2 Koret Way
San Francisco, CA 94143-0606
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