Summer Research Enhancement Program
in Public Health and Health Research 2016
Diné College
Applicant: COMPLETE EACH ITEM TO THE BEST OF YOUR KNOWLEDGE. Incomplete applications
will not be accepted. Selection process will be completed in mid-March 2016. Please provide an
email address you are able to access from March to May 2016 so that we can contact you about
your selection and other details.
PART I – GENERAL INFORMATION
Application Deadline: March 11, 2016
PLEASE PRINT CLEARLY OR TYPE
 Male  Female
Name: (Last, First, MI)
Email Address:
Date of Birth: ____________________SS# ________________
Tribal Affiliation:
Provide a copy of CIB or Tribal ID
.
Will you have a vehicle from June 13 to July 22 to drive to your practicum site for 6 weeks?
Comments:_________________
YES
NO
?___________________________
CURRENT ADDRESS
SUMMER Residence (where you will be living this
Street or P.O. Box #: ___________________________
summer)
City
State
?
Shipping Address (for FEDEX type mailings)
Street or P.O. Box #:__________________________
Zip
City
State
Shipping Address (for FEDEX type mailings)
Zip
Street#: ____________________________________
?
Street#: _____________________________________
?
City
Contact numbers
Telephone: (
?
City
?
Contact numbers
Telephone: (
?
State
Zip
)___________________________
State
Zip
)_____________________________
Message: (
)_______________________________
Message: ( )___________________________________
_________________________________________
)_________________________________________
?
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Please
Fax: ( inform us
) about any physical disabilities, medical conditions or transportation problems, if
applicable._______________________________________________________________________________________
Fax: (
)
?
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Part II – EDUCATIONAL BACKGROUND
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Have
you
convicted
of a felony
or DUI within the past 7 years?
College
orbeen
University
currently
attending:
NO_______________________________________
Address:
City:
College Classification:
 YES 
Cumulative GPA:________
?
State:______ Zip: _________
College Major: _____________________________________
List any honors or awards you have received:
________________________________________________________________________________________________
List clubs or associations you are affiliated with: __________________________________________________________
List other extracurricular
activities:________________________________________________________________________________________
 Word
 Excel
 Power Point  Blackboard
 Online searches to find data for a research paper or report
Check computer applications you have used:
Part III – SCHOOL TRANSCRIPT
Please have official college transcripts from all Universities and College attended sent to: Mark C. Bauer, Ph.D., Diné College –
Shiprock Campus, Summer Research Enhancement Program, Math/Science Department, P.O. Box 580, Shiprock, NM 87420.
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Part IV – ESSAY
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Please write an essay on how your participation in the Summer Research Enhancement Program in Public Health and
Health Research will assist you in achieving your educational future goals and aspirations. Please include your
thoughts on your values and how they can be integrated into a research environment.
Please indicate your focus and what health disparities you have an interest in.
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Please send complete application with two (2) Recommendations to: Mark C. Bauer, Ph.D., Diné College – Shiprock
Campus, Summer Research Enhancement Program, Math/Science Department, P.O. Box 580, Shiprock, NM 87420.
2
Summer Research Enhancement Program in
Public Health and Health Research 2016
Diné College
TO THE PROGRAM APPLICANT: Please print or type your name, address, and the name of the person you
have asked to provide the recommendation. Please ask two professional individuals to complete the
Recommendation Form. The letters of recommendation should be from your science, math, health or
social science instructors who can comment on your academic performance.
__________________________________________________________________________________________
PART V – RECOMMENDATION
__________________________________________________________________________________________
Students Name: (Last, First,
MI)____________________________________________________________________________________________
__________________________________________________________________________________________
___
__________________________________________________________________________________________
Students Mailing Address:
City:
State:__________Zip:________
Recommender’s Name:____________________________________________________________________________
__________________________________________________________________________________________
Department:_____________________________________________________________________________________
__________________________________________________________________________________________
TO THE RECOMMENDER:
__________________________________________________________________________________________
The applicant named above is applying for a position as a student intern in the Summer Research
Enhancement Program. The purpose of the 10-week program is to develop interests and skills
__________________________________________________________________________________________
among Native American freshman and sophomore college students in public health prevention
research.
__________________________________________________________________________________________
__________________________________________________________________________________________
Please complete the information requested on this form. Your comments will be kept completely
confidential. Your candid completion of this recommendation is greatly appreciated.
__________________________________________________________________________________________
__________________________________________________________________________________________
How long and in what capacity have you known the applicant? ________________________________________________________________________________________?
__________________________________________________________________________________________
?
?
__________________________________________________________________________________________
Performs
Requires
__________________________________________________________________________________________
How do you rate the
Accomplished
Does well in
adequately
reinforcement
Not
Applicant?
1
to
5
In
this
area
this
area
in
this
area
in
this
area
observed
__________________________________________________________________________________________
5 being the best student
you have had.
__________________________________________________________________________________________
__________________________________________________________________________________________
Intellectual & Reasoning Ability
__________________________________________________________________________________________
Academic Performance
Maturity
__________________________________________________________________________________________
Initiative
__________________________________________________________________________________________
Responsibility
__________________________________________________________________________________________
Attention to Detail
Oral Communication Skills
__________________________________________________________________________________________
Written Communication Skills
__________________________________________________________________________________________
Motivation and Effort
__________________________________________________________________________________________
Cooperation & Teamwork
__________________________________________________________________________________________
Computer Skills
Research interests
__________________________________________________________________________________________
__________________________________________________________________________________________
__
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Please add your comments, including an assessment of the applicant’s potential performance as a student research
intern. Include such topics as previous accomplishments, intellectual independence, capacity for analytical thinking,
ability to organize and express ideas clearly and creatively, motivation, and scholarly potential. If you need additional
space for your comments, please staple extra papers to this form.
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Please indicate your overall assessment of the applicant:
__________________________________________________________________________________________
__________________________________________________________________________________________
Endorse
Endorse with reservations
Do not Endorse at this time
__________________________________________________________________________________________
Recommender’s Name (Print or Type):
Title:____________________________________________________________________________________________
__________________________________________________________________________________________
School or
__________________________________________________________________________________________
Agency:__________________________________________________________________________________________
Address:
Telephone Number (
Town/City:
)
State:
Zip:________
Email Address:_____________________________________
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Signature: __________________________________________________ Date: ________________________________
Thank you for your valuable assistance
Please send this form to: Mark C. Bauer, Ph.D., Diné College – Shiprock Campus, Summer Research Enhancement
Program, Math/Science Department, P.O. Box 580, Shiprock, New Mexico 87420.
4
Summer Research Enhancement Program in
Public Health and Health Research 2016
Diné College
TO THE PROGRAM APPLICANT: Please print or type your name, address, and the name of the person you have
asked to provide the recommendation.
Please ask two professional individuals to complete the
Recommendation Form. The letters of recommendation should be from your science, math, health or social
science instructors who can comment on your academic performance.
PART V – RECOMMENDATION
?
Students Name: (Last, First, MI)_____________________________________________________________________
Students Mailing Address:
City:
Recommender’s Name:
State:
Zip:__________
Department:____________________________
TO THE RECOMMENDER:
The applicant named above is applying for a position as a student intern in the Summer
Research Enhancement Program. The purpose of the 10-week program is to develop interests
and skills among Native American freshman and sophomore college students in public health
prevention research.
Please complete the information requested on this form. Your comments will be kept completely
confidential. Your candid completion of this recommendation is greatly appreciated.
How long and in what capacity have you known the applicant?
?
? _______________________________________________________
?
How do you rate the
Applicant? 1 to 5
5 being the best student
you have had.
Accomplished
in this area
Does well in
this area
Intellectual & Reasoning Ability
Academic Performance
Maturity
Initiative
Responsibility
Attention to Detail
Oral Communication Skills
Written Communication Skills
Motivation and Effort
Cooperation & Teamwork
Computer Skills
Research interests
5
Performs
adequately
in this area
Requires
reinforcement
in this area
Not
observed
Please add your comments, including an assessment of the applicant’s potential performance as a student research
intern. Include such topics as previous accomplishments, intellectual independence, capacity for analytical thinking,
ability to organize and express ideas clearly and creatively, motivation, and scholarly potential. If you need additional
space for your comments, please staple extra papers to this form.
_______________________________________________________________________________________________
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_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Please indicate your overall assessment of the applicant:
Endorse
Endorse with reservations
Do not Endorse at this time
Recommender’s Name (Print or Type):_______________________________________________________________
Title:____________________________________________________________________________________________
School or
Agency:__________________________________________________________________________________________
Address:
Telephone Number (
Town/City:
)
State:
Zip:________
Email Address:_________________________________
Signature:____________________________________________Date:_____________________________________
Thank you for your valuable assistance
Please send this form to: Mark C. Bauer, Ph.D., Diné College – Shiprock Campus, Summer Research Enhancement
Program, Math/Science Department, P.O. Box 580, Shiprock, New Mexico 87420.
6