THE 2015 RISE PROGRAMS ONLINE GUIDLINES James A. Ferguson Emerging Infectious Diseases Fellowship Program Thank you for your interest in the James A. Ferguson Emerging Infectious Diseases Fellowship Program. THIS IS A SAMPLE APPLICATION PACKET. IMPORTANT: Please review the instructions before beginning the online application. You MUST complete the entire application in one session. This form will NOT save. The SAVE button's only function is to submit the completed application form to the program office. Navigate the form (move from field to field) by hitting the tab button—(if you hit the space bar all previously inputted data will be lost in cyberland!!) At the end of these instructions is the link to the Ferguson Fellowship Online Application. Please note that all applications must be completed using the RISE Programs Online Application. Applications submitted AFTER the deadline of January 31, 2015, 11:59PM EST will automatically be deleted from the database. Please note all applications are automatically dated and time stamped. If applying online poses a hardship, please contact our office during business hours before the closing date for an alternate submission method (443-923-5901). IMPORTANT: Be prepared to complete the application in one session (2 hours), you will NOT be able to save the form and return to complete later, however you will be given the option to PRINT the form upon saving. Have all of your documents readily available and saved in the final formats. Many of the fields are required. The below instructions will help you complete the application. Before opening the application link please review the instructions and the SAMPLE application at the end of the instructions) in detail. You will need to have the following information and electronic documents saved and accessible on the computer, you will be using, to upload into the application or copy and paste into the application. Uploaded files should be in the following format and cannot exceed 25 MB: Resume (Word or PDF format): example: smith_joe_resume Unofficial Undergraduate Transcript ( Word or PDF format): example: smith_joe_undertranscript Unofficial Graduate Transcript (Word or PDF format): example: smith_joe_transcript Have the following items completed and saved in a word document so you can cut and paste into the online application 1. The five (5) Short Answer Responses (maximum 250 words each response) 2. The Essay Questions #1 and #2 (both required—maximum 500 words each essay) Tooltips (hover your mouse over the question mark in the gray circle) will provide information on certain fields and questions. APPLICATION ACKNOWLEDGEMENT Section: Please type your full name in the field provided. Click Sign under the Signature Box. Use your cursor (or if you have a touch screen) sign your name in the box. Click Done, located below the signature box, when completed. 1) When you complete the application return to the top right column of the application and click Save Record; hitting Save Record will SUBMIT your application. If you forget to complete a section, hitting the Save Record button will notify you what required items are missing in the Record Save Checklist (right column). 2) Saving the Record may take a few seconds. Once completed you will be given the option to Close or Print. Please be prepared to print your application or change your print options and print to a PDF. 3) Again, you will NOT be able to save the form AND return to complete later. THE SAVE RECORD BUTTON SUBMITS COMPLETED APPLICATIONS TO THE FERGUSON FELLOWSHIP PROGRAM OFFICE. 4) For your tracking, you will receive the following automatic emails (we recommend you save these emails): A) A confirmation receipt upon submission of your application B) Notification when your referee(s) have submitted a letter of recommendation to the Ferguson Fellowship program office. If you are ready to complete the Ferguson Fellowship Application_PLEASE RIGHT CLICK HERE TO BEGIN (Right click on the TEXT LINK and select Copy Hyperlink, then paste URL into one of the following Browsers: FireFox or Google CHROME). This link can also be found at www.kennedykrieger.org/ferguson-fellowship This is NOT the Online Application—this is a SAMPLE DOCUMENT 10/30/2014 Ferguson Application 2015 Ferguson Application 2015 Application Instructions This application cannot be saved for later completion. Once you begin you must complete. The SAVE button SUBMITS COMPLETED APPLICATIONS to the program office. Applicant Information *Date of Application 10/30/2014 *Name First Middle Last *Date of Birth MM/DD/YYYY *Local Address Address Line 1 Line 2 City City State --Please Select-County County Zip *Email Address [email protected] *Phone: Local ext. *Phone: Home ext. Phone: Cell ext. *Gender Female Male Other *Ethnicity Hispanic or Latino? (Other, please specify ethnicity) Yes No Other *Race (Please select the best description of your race) --Please Select-If requested, Please SPECIFY race details in the box below. https://ctk.apricot.info/document/edit/id/new/form_id/261/ 1/8 10/30/2014 Ferguson Application 2015 *Citizenship Status U.S. Citizen Permanent Resident U.S. National *Primary Language Spoken at Home English Spanish or Spanish Creole Chinese Tagalog French (including Patois, Cajun) Vietnamese German Korean Other *First generational college? Yes No *Pell Grant Eligible Yes No *I learned about the Ferguson Fellowship Program from: --Please Select-- Permanent Residence *Permanent Address Address Line 1 Line 2 City City State --Please Select-County County Zip Education, Experience and Focus *College/University *Minority Serving Institution Historically Black Colleges and Universities (HBCU) Hispanic-serving Asian-serving Tribal Colleges and Universities Other Minority-serving Not-Applicable *Student Classification-Postbaccalaureate Graduate Year --Please Select-*Undergraduate Major Anthropology https://ctk.apricot.info/document/edit/id/new/form_id/261/ 2/8 10/30/2014 Ferguson Application 2015 Biology/Biological Science Business Chemistry Communications Computer Science Economics Education English Engineering Geography Health Education Health Sciences History International Relations Journalism Mathematics Marketing Neuroscience Nursing Pharmacy Psychology Political Science Pre-Dentistry Pre-Med Public Health Sociology Veterinary Medicine Not Specified *Current Major Dental Veterinarian Medicine Medicine Master of Public Health (MPH) Pharmacy *All applicants must answer this question. If you are NOT pursuing a Master of Public Health, please select Not Applicable. MPH majors please identify your area of concentration, select all that apply. Not Applicable Biostatistics Child and Adolescent Health Community Health Education Disaster Management & Emergency Preparedness Epidemiology *My educational track Environmental Health Sciences Master of Public Health Food and Nutrition Other Master's Degree General Public Health Doctorate (e.g. PhD, DrPH) Global HealthDegree (e.g., international Public Health Management) Professional Doctorate (e.g. MD, PharmD, DDS, DVM) Health Disparities HealthisPolicy Management *What your & future career focus and setting? (Please select a Health Focus Systems/Health Services Career and Career Setting.Administration To select multiple items HOLD Ctrl Infectious Diseases and highlight choices. Select all that apply) Maternal and Child Health Clinical Focus Social and Behavior Sciences Public Health Focus Women’s and Reproductive Health Research Focus Other Academic Setting Administrative Setting Community Setting *Anticipated Graduation Date Education/Training Setting MM/DD/YYYY Federal/State/Local Agency Setting Federal (FQHC)/State/Local Health Department Setting *GPA Range National Health Organization Setting 3.0 to 3.4 Non-Profit Setting 3.5 to 4.0 Private/For-Profit Setting Private *CurrentPractice GPA Setting Other 0.0 https://ctk.apricot.info/document/edit/id/new/form_id/261/ 3/8 10/30/2014 Ferguson Application 2015 *Site Preferences CDC, Atlanta, GA Kennedy Krieger Institute/Johns Hopkins Medical Institutions, Baltimore, MD Housing Requests *I need housing for the orientation in Baltimore, MD Yes No *I need housing in Atlanta Yes No *I need housing in Baltimore Yes No *I will need parking information for the summer training site (parking fees are not covered by the Program) Yes No *If you select the Kennedy Krieger Institute/Johns Hopkins Medical Institutions site, would you be willing to commute by train or personal transportation within the Baltimore-Washington, DC metropolitan region for your research experience? Yes No Health Insurance and Emergency Information *Health Insurance Carrier (enter Not Applicable if none) Policy Number Subscribers Name *Emergency Contact Name *Emergency Contact Address Line 1 Line 2 City City State --Please Select-County County Zip *Phone: Emergency Contact ext. *If accepted, will you require special assistance --Please Select-If you require special assistance, please describe the support you will https://ctk.apricot.info/document/edit/id/new/form_id/261/ 4/8 10/30/2014 Ferguson Application 2015 need Notes Name of personal assistant, if applicable Select the top 4 priorities for your preferred site only: CDC Emergency Preparedness Public Health Education --Please Select-- --Please Select-- Epidemiology Public Health Policy --Please Select-- --Please Select-- Public Health Economics --Please Select-Public Health Communication --Please Select-Laboratory Science Public Health Informatics --Please Select-- --Please Select-- Select the top 4 priorities for your preferred site only: Kennedy Krieger Insti Clinical Research --Please Select-- Local Health Department --Please Select-Epidemiology (1) --Please Select-- Pharmacy, Infectious Diseases --Please Select-- Public Health Education (1) --Please Select-State Health Department --Please Select-- Laboratory Science (1) --Please Select-- Short Answers--250 words maximum per question *Describe your past community service, leadership, and/or research experiences. Notes *How do you anticipate participating in the Ferguson Fellowship will help your future career goals? Notes *List any achievements (i.e., honors or awards) Notes *How do you see the attainment of your career goals contributing to public health? Notes *Describe how health disparities impact the prevention, treatment, and https://ctk.apricot.info/document/edit/id/new/form_id/261/ 5/8 10/30/2014 Ferguson Application 2015 control of infectious diseases. Notes Please complete a 500 word essay for each question below *ESSAY NUMBER 1: Which infectious disease(s) are you most interested in learning more about? (500 word maximum) Notes *ESSAY NUMBER 2: Describe your ideal infectious diseases research project, include the public health problem to be addressed, methods and expected results. (500 word maximum) Notes Curriculum Vitae or Resume *ATTACH FILE Choose File No file chosen Up to 25 MB University Undergraduate Transcript--Unofficial *ATTACH Unofficial University Undergraduate Transcript; name must be on printed version-- PLEASE NOTE AN OFFICIAL UNDERGRADUATE TRANSCRIPT IS REQUIRED UPON ACCEPTANCE. Please ensure the transcript includes your name and the school name. Choose File No file chosen Up to 25 MB University Graduate Transcript--Unofficial *ATTACH Unofficial University Graduate Transcript--PLEASE NOTE AN OFFICIAL Graduate TRANSCRIPT IS REQUIRED UPON ACCEPTANCE.Please ensure the transcript includes your name and the school name. Choose File No file chosen Up to 25 MB Letters of Recommendation Two letters of recommendation from faculty at your previous or current university are required. Upon submission (SAVE RECORD) of your application, an email will automatically be sent to each Referee with instructions on how to submit a letter on your behalf. All letters must be uploaded on institutional letterhead using the electronic form provided to the referee. Deadline date for receipt of letters of recommendations is January 31, 2015, 11:59 PM. https://ctk.apricot.info/document/edit/id/new/form_id/261/ 6/8 10/30/2014 Ferguson Application 2015 *Reference 1 Name First Middle Last Middle Last *Referee 1 Institution/Organization *Reference 1 Email [email protected] *Referee 1 Phone ext. *Referee 1 Fax ext. *Reference 2 Name First *Referee 2 Institution/Organization *Reference 2 Email [email protected] *Referee 2 Phone ext. *Referee 2 Fax ext. Consent to Survey Participation *I agree to be contacted to help evaluate the need for summer public health leadership programs. Participation in an end of summer evaluation will include a drawing for a gift card. Yes No Application Acknowledgement *Please type your full name and provide signature in the box using the cursor. By doing so you acknowledge that the information contained in this application is true and accurate to the best of your knowledge and that information may be summarized (without personal identifiers) and shared with the Federal Funding Agency, the Centers for Disease Control and Prevention. Name Full Name Signature To SUBMIT your application https://ctk.apricot.info/document/edit/id/new/form_id/261/ 7/8 10/30/2014 Ferguson Application 2015 To SUBMIT your application, click 'SAVE RECORD'. By saving you will SUBMIT your application to the Program Office. https://ctk.apricot.info/document/edit/id/new/form_id/261/ 8/8
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