Application for Admission
Master of Health Sciences in Clinical Leadership Program
Duke University School of Medicine
Duke University is an Equal Opportunity institution. Duke University offers equal opportunity to all qualified
applicants without regard to race, color, national or ethnic origin, handicap, sexual orientation or preference,
sex, or age. The questions concerning race, sex, and national origin on the application form are for the purpose
of meeting federal reporting requirements and are optional.
Note: See “Information for Applicants” for complete application information. Mail this form to the Clinical
Leadership Program, Department of Community and Family Medicine, Box 104425, Duke University
Medical Center, Durham, NC 27710.
1.
___________________________________________________________________________________
Last or Family Name
First
Middle
Social Security Number ________ - ______- __________
Gender:
Female _____ Male ____
2. Country of citizenship ______________________________________________________________
If not US Citizen, indicate type of visa you hold __________________________________________
3. Date of Birth
__ __ - __ __ - __ __
Month
4. Race/National origin
(check one)
Day
Place of Birth _______________________________
Year
___ White (not Hispanic)
___ Asian or Pacific Islander
___ Black (not Hispanic)
___ Hispanic
___ American Indian or Alaskan Native
5. E-mail address _____________________________________________________________________
6. Home Telephone Number (________) ________________ and Home Mailing Address
_________________________________________________________________________________
Number and Street
City
State
Zip Code
7. DUMC Affiliation (if any) ________________________________________ DUMC Box _________
Department
Division
8. Work Telephone Number (________) ________________ and Mailing Address (if not DUMC)
____________________________________________________________________________________
Number and Street
City
State
Zip Code
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*Official transcripts from all post-secondary/graduate institutions attended must be sent to the
Clinical Leadership Program directly by the institution. Personal copies can not be accepted.
9. List in chronological order all post-secondary colleges and universities attended:
Institution
Location
From
Mo/Yr
Through
Mo/Yr
Major
Field
Degree or
Diploma
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
10. List in chronological order all residency, or fellowship training institutions attended:
Institution
Location
From
Mo/Yr
Through
Mo/Yr
Field
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you have specialty boards or certifications? ___No ___Yes (please specify) _________________
11. Beginning with your current or most recent position, list the last three positions that you have held for
six months or longer:
From
Through
Employer
Location
Mo/Yr
Mo/Yr
Position
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
12. Do you wish to be considered for admission as a degree candidate or as a non-degree
participant? (Check one)
___ Degree candidate
___ Non-degree participant
13. Have you taken the General Aptitude Test (GRE) which is required of all applicants who do not have
a graduate degree?
___ Yes: Date _____-_____
Month
Year
___ No: Date Scheduled _____-_____
Month
___ N/A
Year
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14. List three individuals who will supply letters of evaluation, preferably individuals not all from the
same organization: (Use forms provided.)
Name
Position
Institution
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
15. List any honors, distinctions, prizes or scholarships received:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
16. If you have published papers, list up to three (journal, volume, page numbers and year) and enclose
reprints:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
17. Write a brief statement describing your clinical experience:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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18. Write a brief statement describing your administrative experience (program administration, strategic
planning, supervision, budget preparation/management, etc.)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
19. Write a brief statement describing your most challenging team experience. What did you learn from
this experience?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
20. Write a brief statement stating your career goals and the place of this program in accomplishing those
goals:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
I hereby certify that the information given by me in this application and attached statements is
complete and correct to the best of my knowledge.
____________________________________________
Signature
______________________________
Date
10/2003
Information for Applicants
PROGRAM OPTIONS
Duke’s Master of Health Sciences in Clinical Leadership Program (MHS-CL) offers clinicians an
opportunity to expand their knowledge base and develop leadership skills.
The MHS-CL’s online, distance-based format is designed for professional clinicians. Classes are
scheduled to accommodate the demands of clinical schedules. Classes make use of the students’
experience and students can use their workplaces as “laboratories” in which to practice their new skills.
The program requires attendance at 3-4 day, on-campus sessions in Durham, NC at the beginning of each
term. On-campus dates are scheduled well in advance.
ADMISSION
The Master of Health Sciences in Clinical Leadership is a rolling admissions program. Contact the
program office for each semester’s application and registration deadlines. To be considered for
admission, candidates must have all application materials submitted by the designated deadline for
the semester for which they wish to begin the program. Materials received after the application
deadline will automatically be considered for the following semester.
Applicants seeking admission as a degree candidate or as a non-degree auditing student should submit the
application form and provide the following supporting documents. Non-degree candidates and auditing
learners are not required to complete an Admission Committee interview.
Transcripts. An official transcript from each post-secondary institution attended must be sent
to the Clinical Leadership Program directly by the institution. Personal copies are not acceptable.
Letters of Evaluation. Three letters are required. One letter must come from someone who
can testify to your clinical experience and one letter must come from someone who can testify to
your administrative experience. All letters should be written by persons who are qualified to
testify to your capacity for graduate work. Evaluation forms are provided; they should be mailed
to the Clinical Leadership Program directly by the evaluators.
Test Scores. Applicants who do not possess a graduate degree are required to provide scores
on the Graduate Record Examination (GRE) General (Aptitude) Test. The scores must not be
more than five years old and they must be mailed to the Clinical Leadership Program from the
Educational Testing Service.
Admissions Interview. Applicant finalists will be required to complete an admissions
interview.
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APPLICATION FEE
The non-refundable $100 application fee must be included with the application for it to be considered
complete. Checks should be made payable to “Clinical Leadership Program.”
TUITION
Effective July 2013, tuition for the degree program is a total of $50,400. Students are billed each
semester. Once a student is admitted to the program, a non-refundable tuition deposit of $500 is required
within ten days of admission to reserve a spot in the class. This amount is applied to the first tuition
payment.
Some students fund their own education, and others are sponsored entirely or in part by their employer.
For those who are self-funded, Duke’s School of Medicine Office of Financial Aid offers resources
regarding loans and scholarships. We encourage you to contact them as soon as possible to begin that
process.
FOR MORE INFORMATION
Visit our website: http://clinical-leadership.mc.duke.edu or contact
Claudia J. Graham at 919.681.5724 or Claudia.Graham@duke.edu
Division of Community Health
Department of Community & Family Medicine
DUMC Box 104425
Durham, NC 27710
919-681-5724
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