Preventive Medicine Resident Practicum Program Application

APPLICATION DEADLINE: Monday, March 2, 2010 (Midnight)

Directions: Provide all information, filling out the form as completely and accurately as possible. You only need to submit the form once, even if you are applying to both AHRQ and ODPHP. Please review the form and collect the information before starting; information on incomplete forms will not be retrievable.

Office

* Please select the office you are applying for. Please read the descriptions of each for more guidance.

AHRQ (will need a scientific writing sample)

ODPHP (will need a statement of interest)

Both AHRQ and ODPHP (will need a scientific writing sample and a statement of interest)

Personal Information

* First Name

* Last Name

* Address 1

Address 2

* City

* State

* Postal Code

* Phone

* Email Address

Residency Program

* Name of Residency Program

* Name of Residency Program Director

* Phone

* Email Address

* Address 1

Address 2

* City

* State

* Postal Code

Availability

* Please select your rotation period preferences in two- to three-month intervals for each 1st, 2nd and 3rd choice.

Please list your rotation period preferences in two- to three-month intervals.

* First choice of months for rotation

* Second choice of months for rotation

* Third choice of months for rotation

Credentials

Please attach your current CV or resume as a PDF file.
Select the upload button to complete the attachment.

Letter of Recommendation

A letter of recommendation is required from the Residency Program Director to state support for the applicant as a qualified candidate for the APTR Preventive Medicine Resident Practicum Program. Recommendations written by the Director must be attached as a PDF below.

Please attach Director's letter of recommendation as a PDF file.
Select the upload button to complete the attachment.

Sample of Scientific Writing (AHRQ)

Please enclose a sample of scientific writing not to exceed two pages:

The sample may be from published or unpublished sources.
You must be the primary author of the document. If there are multiple authors, please clearly identify which pieces were written by you.
The sample must be on a health-related topic, preferably in prevention, public health, or health policy.
Bibliographies do not count toward the two page maximum length.

Please attach a scientific writing sample as a word document or .pdf file
Select the upload button to complete the attachment

Applicant Statement of Interest (ODPHP)

Please enclose a statement not to exceed two pages describing:

The subject matter area(s) on which you would like to focus during a rotation at ODPHP
The reasons for your interest in and prior experience in these subject area(s)
The personal and professional goals for your residency rotation at ODPHP

Please attach your statement of interestas a word document or .pdf file
Select the upload button to complete the attachment

Applicant Affirmation

By submitting this form, I certify that I am eligible to apply to the APTR Preventive Medicine Practicum Program and the information that I have provided in this application is complete and accurate.

* By checking this box, I affirm my eligibility and that the application has been completed to the best of my ability.

I am eligible and this form has been completed to the best of my knowledge.

Questions

For more information or questions about this application, please contact:
202.463.0550, ext. 123 or training@aptrweb.org

* Indicates Response Required

	1st Choice	2nd Choice	3rd Choice
January
February
March
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