Interdisciplinary Fellowship Application

Interdisciplinary Fellowship Application

Division of General Pediatrics and Adolescent Health

Department of Pediatrics

Applicant Information

Full Name:
Last / First / M.I.
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Phone(s): / ( ) - / e-mail:
( ) -
Are you a U.S. citizen? / ☐ Yes ☐ No / ☐
Are you a permanent U.S. resident? / ☐ Yes ☐ No

Voluntary Information

The information requested below is voluntary and is intended to help the us meet our federal reporting obligations. It will not be used as a basis for admission or in a discriminatory manner.

Are you Hispanic or Latino/a?

☐ / Yes / ☐ / No

What is your race? If more than one describes you, mark all that apply.

☐ / American Indian/ / ☐ / Black/African/ / ☐ / White
Alaskan Native / African American
☐ / Asian / ☐ / Native Hawaiian or / ☐ / Other
Other Pacific Islander
Please indicate your gender identity:
☐ / Man / ☐ / Woman / ☐ / Other

Please check one or more options for the set(s) or pronouns you prefer people to use for you.

☐ / She/Her / ☐ / He/Him / ☐ / They /Theirs / ☐ / Other

Current Health Discipline

Please indicate your current discipline

☐ / Family Social Science / ☐ / Nursing / ☐ / Other
☐ / Medicine / ☐ / Nutrition
☐ / Adolescent Medicine / ☐ / Psychology
☐ / General Pediatrics / ☐ / Public Health
☐ / Other Medicine / ☐ / Social Work
Education

Please list below all colleges and graduate and post-graduate schools attended, beginning with the most recent. Please note: To complete your application, official transcripts must be received from all graduate degree programs and from your college of graduation.

College or University / Degree / Year Completed / Field
Experience

Please list all employment pertinent to your application, beginning with the most recent.

Employer (Supervisor) / Dates of Employment / Nature of Employment
References

Please note: Three letters of reference must be received to complete your application. You are responsible for contacting these individuals for letters of reference. Please list three (3) individuals who can evaluate your academic and/or professional work. The writers should address the issues of clinical performance, interpersonal and teaming skills, academic skills, and leadership ability. In addition, we would like your permission to contact your references for further information or clarification, if needed. See statement requiring your signature on the last page.

Name/Address / Phone / e-mail
Directed Questions

Please cut and paste your answers into the box below OR you may send your Directed Questions as an attachment along with the application.

1. After you have had an opportunity to read the descriptive materials, please write a statement that addresses the nature and origin of your interest in children or youth; experiences you have had working with children or youth; what you hope to gain from the Fellowship Training Program; and your contribution to it. Please be as specific as possible, and feel free to add anything that will help us in considering your application.

2. Please describe any experience you may have had around scholarly work or research, including your own original work, as well as work done in collaboration with others. Specify the kinds and extent of your involvement in research.

3. Please state as clearly as you can what type of employment you would anticipate upon completion of your fellowship training.

I hereby submit my application for fellowship training to the University of Minnesota; and grant permission for the Fellowship representative to contact my listed references for further information or clarification.

Signature of Applicant / Date

Send application, reference letters and curriculum vitae to:

Judith A. Kahn, M.S.W.

Interdisciplinary Fellowship Training Manager

Division of General Pediatrics and Adolescent Health

Department of Pediatrics

717 Delaware Street SE, 3rd Floor

University of Minnesota

Minneapolis, MN 55414

phone: 612-626-1835

e-mail:

Disciplinary Faculty Contacts
Adolescent Medicine / Nimi Singh, MD, MPH
Phone 612-625-5497

Developmental-Behavioral Pediatrics / Andrew Barnes, MD
Phone 612-624-1167

Healthy Youth Development • Prevention Research Center / Renée Sieving, PhD, RN, FAAN, FSAHM
Phone 6126264527

Nursing (Adolescent Health) / Renée Sieving, PhD, RN, FAAN, FSAHM
Phone 6126264527

Nutrition (Adolescent Health) / Dianne Neumark-Sztainer, RD, PhD
Phone 612624-0880

Primary Care Academic General Pediatrics / Iris W. Borowsky, MD, PhD
Phone 612-6262398

Interdisciplinary Research Training in Child &
Adolescent Primary Care / Iris W. Borowsky, MD, PhD
Phone 612-6262398

Social Work (Adolescent Health) / Paul Snyder, MSW, MDiv
Phone 612-626-8412

Updated 10/26/2017

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