Dermatology NIH Training Grant Application

Dermatology Fellowship Application

If you are interested in applying for a position on our NIH T32 Dermatology Training Grant, please provide us with your contact information, voluntary demographic information, the type of fellowship you are interested in applying for, your academic information, and your research interests, by filling in the online form below. This information will be held in strict confidence, and will be used solely for the purposes of evaluating training grant applicants and for monitoring the diversity of our applicant pool.

Name

Address

City

State

Zip

Country

Phone Number

E-Mail Address

What type of fellowship are you applying for?

Pre Doctoral (short term med student) - 2-3 Months
Pre Doctoral (long term med student) - 1 year or more
Post Doctoral - 2 year commitment

Are you a US Citizen or Permanent Resident?

By the time of award, candidates for pre- or post-doctoral awards must be citizens or non-citizen nationals of the United States, or must have been lawfully admitted to the United States for Permanent Residence (i.e., possess a currently valid Alien Registration Receipt Card I-551, or other legal verification of such status). Non-citizen nationals are generally persons born in outlying possessions of the United States (i.e., American Samoa and Swains Island). Individuals on temporary or student visas are not eligible.

Yes No

Demographic Information

The Dermatology training program seeks to draw trainees from diverse backgrounds. The information requested below will be used to evaluate the effectiveness of our recruitment efforts and to facilitate selection of a diverse group of trainees. We would like to know how your background, work and life experiences, interests, culture, socioeconomic status, race and/or ethnicity will contribute to the diversity of our trainee profile. This infomation is CONFIDENTAL AND COMPLETELY VOLUNTARY. Answering a question or omission of an answer will not influence decision of admission to the program.

Do you:

Have a disability (a physical or mental impairment that substantially limits one or more major life activities):

For purposes of nondiscrimination laws (e.g. the Americans with Disabilities Act, Section 503 of the Rehabilitation Act of 1973 and Section 188 of the Workforce Investment Act), a person with a disability is generally defined as someone who (1) has a physical or mental impairment that substantially limits one or more "major life activities," (2) has a record of such an impairment, or (3) is regarded as having such an impairment.

Yes No Prefer not to answer

Come from socially/culturally/educationally disadvataged background:

Individuals who come from a social, cultural, or educational environment such as that found in certain rural or inner-city environments that have demonstrably and recently directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a research career.

Yes No Prefer not to answer

Family has an annual income below established low-income thresholds:

These thresholds are based on family size, published by the U.S. Bureau of the Census; adjusted annually for changes in the Consumer Price Index; and adjusted by the Secretary for use in all health professions programs. The Secretary periodically publishes these income levels at http://aspe.hhs.gov/poverty/index.shtml. For individuals from low-income backgrounds, the institution must be able to demonstrate that such candidates (a) have qualified for Federal disadvantaged assistance; or (b) have received any of the following student loans: Health Professional Student Loans (HPSL), Loans for Disadvantaged Student Program; or (c) have received scholarships from the U.S. Department of Health and Human Services under the Scholarship for Individuals with Exceptional Financial Need.

Yes No Prefer not to answer

In the first generation of your familiy to attend college:
Yes No Prefer not to answer

Gender:

Male Female

Race:

Which best describes you?

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, the Philippine Islands, India, Pakistan, Malaysia, Japan, Cambodia, China, Korea, Thailand, and Vietnam.

Black or African American - A person having origins in any of the black racial groups of Africa. Terms such as 'Haitian' or 'Negro' can be used in addition to 'Black' or 'African American.'

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Some other race

Two or more races

Check all that Apply:

American Indian or Alaskan Native
Asian
Black or African-American
Hawaiian or other Pacific Islander
White
Other
Prefer Not to Answer

Ethnicity:

Which best describes you?

The heritage, nationality group, lineage, or country of birth of the person or the person 's parents or ancestors before their arrival in the United States. People who identify their origin as Spanish, Hispanic, or Latino may be of any race.

Select one:

Hispanic or Latino
Not Hispanic or Latino
Prefer Not to Answer

Academic Information

Please Enter Your Education History Below

Degree

University Attended

GPA

Year

Degree

University Attended

GPA

Year

Degree

University Attended

GPA

Year

Degree

University Attended

GPA

Year

Degree

University Attended

GPA

Year

Highest PGY*

Pre Doc applicants, please click here for additional education questions.

Post Doc applicants, please click here for additional education questions.

Research Interests
*Please select no more than 5

Faculty Selection
With whom would you like to work?
*Please select no more than 5

Supplemental Document Upload

If you have a CV or resume, please submit it here.