Student/Resident
Experiences And Rotations
in Community Health
Sponsored by the National Health Service Corps (NHSC)
UNMC Rural Health Education Network (RHEN)
and the Nebraska Area Health Education Centers (AHECs)
SEARCH Application Form
* Required
Fields
|
| Personal
Information |
| Applicant
Name |
First:
*
|
Middle:
|
Last:
*
|
Past
Last Name:
|
| Current
mailing address:
*
|
City:
*
|
State:
*
|
Zip:
*
|
County:
*
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| Permanent
mailing address:
Same as Current mailing address
|
|
Street address:
*
|
City:
*
|
State:
*
|
Zip:
*
|
County:
*
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E-mail
address:
*
|
Home
Phone:
*
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Cell
Phone:
|
|
Last 4 digits of SSN:
*
|
Date
Of Birth:
*
(MM/DD/YYYY)
|
Gender:
*
Male
Female |
Ethnicity
* Are you Hispanic/Latino:
Yes
No
|
Race
*
|
White/Caucasian
Black/African American
Asian
Native Hawaiian/Pacific Islander
Native American/Alaskan Native
Unknown
Undeclared
More than 1 race
Other, if other, please specify: *
I choose not to answer
|
| Please
check the appropriate category to describe yourself. Student applications
to participate in the Nebraska SEARCH Program are prioritized using the
following criteria:
* |
NHSC Scholar
Nebraska resident in Nebraska training program
Non-Nebraska resident in Nebraska training program
Nebraska resident/former resident in non-Nebraska training program
Non-Nebraska resident in non-Nebraska training program |
| Do
you speak any languages other then English?
yes
no
|
| If
yes, what language?
|
| Level
of fluency:
High
Moderate
Low
|
Emergency
Contact Information: |
Contact
1:
*
|
Relation:
|
Home
Phone:
*
|
Work
Phone:
|
Cell
Phone:
|
Contact
2:
*
|
Relation:
|
Home
Phone:
*
|
Work
Phone:
|
Cell
Phone:
|
| Educational
Information |
| High
school graduation |
High
School Name:
*
|
Graduation:
Month:
*
(MM) Year:
*
(YYYY) |
City:
*
|
State:
*
|
County:
*
|
Educational Status:
Current Student
Medical or Dental Resident
|
For
current students: |
| Current
University/College Name: *
|
| Street
Address:
|
City: *
|
State:
|
Zip:
|
County:
*
|
| Discipline
or Program: * |
Medical (MD/DO) * |
Pharmacy |
Clinical
psychologist (PhD) |
family practice
pediatrics
other
*
|
Dentistry |
Clinical
Social Work (MSW) |
|
Dental Hygiene |
Marriage/Family
Therapist |
Nurse
Practitioner
|
Certified nurse mid-wife
|
| specialty
*
|
|
|
| Physician
Assistant |
|
|
| Year
in school: *
1st year
2nd year
3rd year
4th year |
Expected
graduation date: *
Month:
(MM) Year:
(YYYY) |
For
medical or dental residents: |
|
Degree: *
M.D. (or D.O.)
D.D.S.
|
Degree
awarded from: *
|
| City: *
|
State: *
|
Graduation
Date: * Month:
(MM)
Year:
(YYYY) |
| Residency
Program: *
|
Institution:
*
|
Current
year in residency: *
1st year
2nd year
3rd year
4th year |
Expected
completion date: *
Month:
(MM)
Year:
(YYYY) |
| Program
Director: *
|
E-mail:
|
Phone:
|
Rotation
Information: |
| Has
your school/program already placed you in a clinical rotation?
*
yes
no |
|
If yes, please give
preceptor contact information
|
|
|
Name of Facility: *
|
Preceptor name: *
|
| City:
*
|
State:
*
|
Zip:
*
County: *
|
Rotation
Begin Date: *
(MM/DD/YYYY)
|
Rotation
End Date: *
(MM/DD/YYYY)
|
| Student
Rotation Advisor: *
|
E-mail:
|
Phone:
|
|
Will you receive
academic credit for this rotation?*
yes
no |
Is housing provided?*
Yes
No
If no, please complete
the following housing questions:
Housing - Do you have any special circumstances that should be considered
if housing is provided for you? *
Yes
No
|
| |
Do
you smoke? *
Yes
No
Do you have allergies? *
Yes
No
If yes, specify: *
Other
(i.e., spouse, children, accessibility, etc.):
|
| If
your school/program has not placed you in a clinical rotation, what
area of Nebraska are you interested in?
*
Central NE
Southeast NE
Panhandle
Northern Nebraska
Undecided
|
Applicant
Profile: |
List
any prior work or education experience you have had in providing care
to the underserved.
*
List your goals/reasons
for applying. Why do you want this experience?
*
Describe what
you think community-based primary care is and what working in an interdisciplinary
environment entails.
*
What is your
hometown when not in school?
*
|
| What
type of community interests you most for a future practice?
* |
Do you have an obligation to establish in a certain location or type of
practice (rural, underserved, military) upon graduation?
*
Yes
No
Who gave you this obligation (state, federal, etc)? |
| Type: *
|
Number
of years: *
|
Obligation
to whom: *
|
Rank
the following factors impacting your decision to do this program (1=
most important, 6 = least important)
*
Clinical
Experience
Source of
income
Career Decision
Making
Cultural
Experience
Interdisciplinary
Experience
Other *
How did you hear
about this program?
* |
Web site
Other student
AHEC office contacted me |
Class presentation
Other: *
|
Notes:
For
Federal Reporting Purposes:
Would you consider yourself "disadvantaged" (using the definition
provided)?
*
yes
no
"A "disadvantaged"
individual is one who comes form an environment that has inhibited
the knowledge, skills, and abilities required to enroll in and graduate
from a health professional training school, or from a program providing
education or training in an allied health profession." OR "A
disadvantaged individuals comes from a family with an annual income
below a level based on low-income thresholds set by the US government."
Definition from the US DHHS Health Resources and Serv
shortnoteices Administration.
|