Alabama’sCommunity Research FellowsProgram

Application Form

Thank you for your interest in the Community Research Fellows Program. Gulf States Health Policy Center and The University of Alabama at Birmingham’s Minority Health and Health Disparities Research Center (MHRC)areseeking dedicated community membersto participate in an evidenced-based public health training to address identified health disparities in your communities.

Please note: A completed application must include the following:

Community Research Fellows Program Application Form

Resume

2 Reference letters (one professional and one personal)

* Applications will be reviewedto determine acceptance or waitlist.*

Name: ______

Address: ______

Email Address: ______Phone number: ______

What is your age? ______

Organization/Affiliation: ______

Gender: [ ] Male [ ] Female

Race: [ ] African American/Black[ ] White [ ] Asian/Pacific Islander

[ ] Native American/Alaska Native[ ] Multi-racial[ ] Other ______

Ethnicity: [ ] Hispanic or Latino[ ] Non-Hispanic or Latino

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Highest Level of Education:

Elementary school / Some college or Associate degree
Junior high or some high school / College degree
High school diploma / Graduate degree
Graduate Equivalency Diploma (GED)

Current Role:

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[ ] Academic

[ ] Government

[ ] Community Based Organization

[ ] Healthcare worker

[ ] Faith-based Organization

[ ] Community Member

[ ] Other

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1. Why are you interested in the Community Research Fellowsprogram?How do you plan to use the skills from this training? ______

______

2. A. Have you ever participated in research before? Yes [ ] No [ ]

B. Have you ever conducted research before? Yes [ ] No [ ]

If yes, please specify type of project and role: ______

3. Have you ever participated in community based participatory research initiatives? Yes [ ] No [ ]

If yes please specify: ______

4. Do you think it’s important for community members to understand research? Yes [ ] No [ ]

If yes why? ______

______

5. Can youcommit to a three-hour class, once a week, for 16weeks? Yes [ ] No [ ]

6. What civic organizations/community based organizations are you involved in?

Organization Role Dates (Start-End mm/dd/yy)

7. In your opinion, what are the top three areas of concern in Alabama’s minority communities?

1)______

2)______

3)______

8. What area(s) are you interested in to improve the well-being of your community?

______

9. How did you hear about Gulf StatesCommunity Research Fellows Program? Check all that apply.

Email [ ] Webinar [ ] Friend/Colleague [ ] Flyer [ ] Other: ______

10. If you attended the webinar, how helpful was the information presented?

Very HelpfulHelpfulNeutral Unhelpful Very Unhelpful

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I verify that I have completed this application to the best of my knowledge and have provided a resume and two reference letters.

______

Name (Print Please)Signature Date

Applications are due November3, 2017

Please send the completed application with your resume and two reference letters to:

Bianca Hawk, MSW, MPH

UAB

Minority Health and Health Disparities Research Center

Gulf States Health Policy Center

1717 11th Ave South Suite 516E

Birmingham, AL 35294-4410

Phone: 205-996-2432

Or email

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