Transitional and Community Care Experiential Education and Training Program July 2023

Northwestern University
Transitional and Community Care Experiential Education and Training Program July 2023
Applications will be accepted on a rolling basis between June 1, 2023 and January 1, 2023.

Name Name Title First Middle Last Suffix
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
In case of emergency contact
Emergency contact phone Emergency contact phone - ### - ### ####
Are you a citizen of the United States, a non-citizen US national, or Permanent Resident (I-551 or I-151)?

Are you a citizen of the United States, a non-citizen US national, or Permanent Resident (I-551 or I-151)? Yes No
Date Date / MM / DD YYYY
Do you have any disabilities or limitations that would prevent you from performing the responsibilities of this Fellowship?

Do you have any disabilities or limitations that would prevent you from performing the responsibilities of this Fellowship? Yes No
Please tell us how you heard about the fellowship program (check all that apply):

Please tell us how you heard about the fellowship program (check all that apply): SGIM Website Advisor / Mentor Friend or Associate Other Other
Education, Licensure and Experience
High School
College
Medical School
Graduate School
Internship and Residency Training
Subspecialty Board Certified
Fellowships
Have your privileges at any hospital or other facility ever been denied, limited, suspended, revoked, or not renewed?

Have your privileges at any hospital or other facility ever been denied, limited, suspended, revoked, or not renewed? Yes No
Have you ever been denied membership, a renewal, or subjected to disciplinary action by any hospital or medical organization?

Have you ever been denied membership, a renewal, or subjected to disciplinary action by any hospital or medical organization? Yes No
Has your license to practice medicine in any jurisdiction ever been limited, suspended, or revoked?

Has your license to practice medicine in any jurisdiction ever been limited, suspended, or revoked? Yes No
Have you ever voluntarily relinquished your license?

Have you ever voluntarily relinquished your license? Yes No
National and State Board Examinations (USMLE or equivalent):

This is the description of your section break.
USMLE Date and Scores Step I:
USMLE Date and Scores Step II:
USMLE Date and Scores Step III:
Clinical Skills Assessment Test Score:
Career Plans (Please be as specific as possible. Your response should be 300-500 words)
Why are you interested in the Transitional and Community Care Experiential Education and Training Program?
Please describe your academic interests
Please specify 1 or 2 projects you might work on during this experiential education program (patient experience, health equity, health-related social needs, quality improvement, etc.)
What do you hope to accomplish throughout this program and how will it advance your skills and career?
Describe the position you think you would want after completing this program
Describe your longer-term goals (5-10 years)
Curriculum Vitae

Please upload a current CV. On the CV, include a list of your publications and other scholarly work with separate sections for original research articles; reviews and editorials; book chapters; other publication types; manuscripts under review; oral presentations at regional or national meetings; and poster presentations at regional or national meetings.
Upload CV

Attach Files
References

Please arrange to have three letters of reference submitted to Kel Kennedy (kelly.kennedy@northwestern.edu) by January 1, 2023. One must be from your current or most recent clinical training program.

Name
Address
Title
Preferred Method of Contact
Upload list of references we should expect to receive.

Attach Files
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Transitional and Community Care Experiential Education and Training Program July 2023

Transitional and Community Care Experiential Education and Training Program July 2023

Education, Licensure and Experience

National and State Board Examinations (USMLE or equivalent):

Career Plans (Please be as specific as possible. Your response should be 300-500 words)

Curriculum Vitae

References