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: *
Permanent mailing address:    Same as Current mailing address
Street address: *  
City: * 
State: *   Zip: * 
County: * 
E-mail address: *
Home Phone:   *
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? * 
under 5,000 5,000 – 10,000 10,000 – 25,000 25,000 – 100,000 over 100,000
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

Community Experience

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.