OHSU SOM Division of Management Programs
Scholarship Application - 2016 /

To be completed by the employee requesting the scholarship.

Part 1: Employee Information

Name / Click here to enter text. /
Employee # / Click here to enter text. /
Position / Click here to enter text. /
Phone # / Click here to enter text. /
OHSU Department / Click here to enter text. /
Supervisor/Manager / Click here to enter text. /

Part 2: Name of Program

Please check the box next to the program for which you are requesting a scholarship:

☐ Graduate Certificate in Healthcare Management Program

☐ Master of Science in Healthcare Management

☐ Healthcare MBA

Part 3: Objectives & Goals
Please answer the following eight items. Enter your responses in the green shaded areas below each question. These will expand to accommodate your responses. Use as much space as needed.

  1. Describe your education and professional background.

  1. Describe your interest in the Certificate program and scholarship.

  1. How does this academic program align with your personal and the department goals?

  1. How will your completion of this program benefit you (personally and professionally), your department and OHSU?

  1. How do you plan to apply what you learn to the workplace?

  1. Describe your participation in any and all of the following:
  2. Committee(s) or task force(s)
  3. Project(s) in which you made a significant contribution that led to improved performance in a key area (quality, safety, service, efficiency, finance, growth, diversity)

  1. List all committees and task forces you have participated in.

  1. Have you served in a leadership role on a project or in an interim capacity in absence of a leader? If yes, please describe.

Part 4: Scholarship Certification

Please accept my application for a scholarship to help defray costs associated with participation in the SOM Division of Management Program. I understand that the availability of funds is contingent on my successful acceptance into the program. I understand that the organization is willing to invest in my development and in return, I make the personal commitment to successfully complete all coursework within the standard 6-quarter timeframe and to apply what I learn to advance OHSU interests. I accept that, in the event I do not complete coursework or voluntarily leave work prior to completion of two years of service post-coursework completion, I am obligated to repay funds paid on my behalf on a pro-rata basis, i.e. 1/24th of the amount expended for each month remaining in the 24 month period. I authorize full or partial recovery of funds from monies due me from OHSU coincident with my separation and, if my obligation is not paid in full at that time, establish a repayment plan prior to my last day of work.

Signature / Click here to enter text. /
Date / Click here to enter text. /

Submit your complete scholarship packet (all three documents)
to Jessica Walter
include “Scholarship” as the subject line
by 11:00pm Friday, July 8, 2016.