_______________________________________________________________________________________________________
Primary Care Physician Scientist Program
Division of General Internal Medicine
Hospital of the University of Pennsylvania
Philadelphia, PA
Application for the Fellowship in
General Internal Medicine and
Clinical Epidemiology
Hospital of the University of Pennsylvania
Fellowship in General Internal Medicine and Clinical Epidemiology
Application Instructions
Please note: We have a rolling admissions policy with the final application deadline being November 30, 2014 for
admission in July 2015. (Applications may be accepted after this date, but consideration for funding requires a
timely application submission). Classes for the Program start on July 1, 2015.
1) Please fill out the application in its entirety. Do not put “refer to CV” for any of the information requested.
2) In addition to the application, we request the following information be submitted to the address below.
Electronic submissions are prefered:
a. Personal Statement
i. Please discuss your clinical background, research interests, and reasons for pursuing the
Fellowship.
b. Curriculum Vitae
c. 3 Recommendations
d. MCAT or GRE report
e. Official, Sealed Transcripts from All Relevant Undergraduate and Graduate Institutions.
f. Picture of Yourself (optional)
3) The reference form should be sent electronically to the three people who will be writing recommendation
letters on your behalf. They should:
a. Fill out the form and write a letter.
b. Sign the form and the accompanying letter.
c. The signed form and letter can be sent electronically, faxed, or mailed to the address below.
4) Your application will be reviewed when the application and all supporting documents have been received.
5) If you have any questions, contact Elliot Adler.
MSHP
c/o Elliot Adler
1310 Blockley Hall
423 Guardian Drive
Philadelphia, PA 19104
Tel: 215-573-2740
Fax: 215-573-2742
elliota@mail.med.upenn.edu
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Personal Information
First Name:
Last Name:
Date of Birth:
Address:
Phone Numbers:
Phone type
Phone type
Phone type
Email:
Citizenship:
If not a US citizen, are you a Permanent Resident?
Please indicate your current Penn affiliation: Select One Other (if not in list):
(if you answered “Not Affiliated”, please skip to Application Details below)
Penn Affiliation Title:
Department:
Location:
Department Business Administrator:
BA Phone:
Application Details
Year of Desired Enrollment:
2015
Educational Background
Please list all higher education schools attended in chronological order (do not enter “refer to cv”)
Institution/Location
Dates
Attended
Degree
Graduation
Date
Major
GPA
Test Scores: A GRE or MCAT score is required for consideration in the program. If you have not completed either for these tests, you must
request a waiver from the requirement. The waiver request must include justification for why you think you should not have to take the GRE
or MCAT. The waiver request must either precede or accompany this application.
GRE
Verbal
Date taken:
V%
MCAT
Verbal
Date taken:
Quantitative
Physical. Science
Q%
Analytical
Writing
A%
Biology
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Post Graduate Experience
Training: Please list any post-graduate training including internships, residency, fellowships and other appointments
Title
Institution/Location
Specialty
Dates
Work Experience
Research Positions: Please include all relevant research experiences (whether laboratory based or clinical) and health policy experiences
(full or part-time)
Position
Institution (name and location)
Dates
Academic Honors and Honorary Societies
Title
Date
Board Certification Status
Are you board eligible?
Board :
Select
Have you taken the exam?
Select
Date of Certification:
References
Please list the names, titles, and institutions of three individuals who have known you professionally whom you have asked to send provide
reference letters. One should be the Director of your current program.
Name:
Institution:
Name:
Institution:
Name:
Institution:
Title:
Phone:
Email:
Title:
Phone:
Email:
Title:
Phone:
Email:
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Work Experience
Demographic Data
The University of Pennsylvania seeks to draw students from diverse backgrounds. The information requested below will be used to evaluate
the effectiveness of our recruitment efforts and to facilitate selection of a diverse student body. This information is COMPLETELY
CONFIDENTIAL. Answering these questions will NOT influence the University’s decision on admission.
1. Are you Hispanic or Latino?
No
Yes, Hispanic or Latino (including Spain)
If yes, please check all that apply below:
Which best describes your background?
Central America
Cuba
Mexico
Puerto Rico
South America (excluding Brazil)
Spain
Other
____________________________________
2. Regardless of your answer to the prior question, please check one or more of the following groups in
which you consider yourself to be a member:
American Indian or Alaska Native (including all Original Peoples of the Americas)
Which best describes your background?
Alaska Native
Chippewa
Choctaw
Cherokee
Are you enrolled?
Navajo
Sioux
Other
No
Yes, please enter tribal enrollment number
____________________________________
___________
Asian (including Indian subcontinent and Philippines)
Which best describes your background?
China
India
Japan
Korea
Pakistan
Philippines
Vietnam
Other East Asia
____________________________
Other Indian Subcontinent
___________________
Other Southeast Asia
_______________________
Black or African American (including Africa and Caribbean)
Which best describes your background?
U.S. / African American
Africa
Caribbean
Other
____________________________________
Native Hawaiian or Other Pacific Islander (Original Peoples)
Which best describes your background?
Guam
Hawaii
Samoa
Other Pacific Islands (excluding Philippines)
_____
White (including Middle Eastern)
Which best describes your background?
Europe
Middle East
Other
______________________________
3. Do you come from a family with an annual income below established low-income thresholds?
Low income Thresholds can be found at: http://aspe.hhs.gov/poverty/13poverty.cfm.
Yes
No
Prefer not to answer
4. Are you the first generation in your family to attend college?
Yes
No
Prefer not to answer
5. Have you attended a historically black college or university (HBCU)?
Yes
No
Prefer not to answer
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Academic Integrity/Mandatory Question
1.
Have you ever been placed on probation, dismissed or suspended from any college or university for reasons
pertaining to academic integrity?
Yes
No
(If yes, your Personal Statement should include any facts that you believe bear on the significance of this circumstance.)
Prior Conviction
If you have ever been convicted of, or pled guilty, or no contests, to any felony or misdemeanor (excluding minor traffic violations)
follow this secure link: https://medley.isc-seo.upenn.edu/gradAdmissions/jsp/fast.do?fastStart=priorConvictions and provide
further information on a confidential basis. In the field titled “School/program to which you are applying,” select Biomedical
Graduate Studies.
Additional Documentation Required
By checking this box, you are attesting to the accuracy and validity of the information provided in this application. The
application will not be accepted without a check mark in this box. Any falsified information will result in immediate
disqualification for consideration for admission or withdrawal from the program if admission has already occurred.
The University of Pennsylvania values diversity and seeks talented students, faculty and staff from diverse backgrounds. The University of
Pennsylvania does not discriminate on the basis of race, color, sex, sexual orientation, gender identity, religion, creed, national or ethnic
origin, citizenship status, age, disability, veteran status or any other legally protected class status in the administration of its admissions,
financial aid, educational or athletic programs, or other University-administered programs or in its employment practices. Questions or
complaints regarding this policy should be directed to the Executive Director of the Office of Affirmative Action and Equal Opportunity
Programs, Sansom Place East, 3600 Chestnut Street, Suite 228, Philadelphia, PA 19104-6106; or (215) 898-6993 (Voice) or (215) 898-7803
(TDD). Specific questions concerning the accommodation of students with disabilities should be directed to the Office of Student Disabilities
Services located at the Learning Resources Center, 3820 Locust Walk, Harnwell College House, Suite 110, 215.573.9235 (voice) or
215.746.6320 (TDD).
Federal law, the Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act, requires all institutions of higher
education to provide information on their security policies and procedures and specific statistics for criminal incidents and arrests on campus
to students and employees, and to make the information and statistics available to prospective students and employees upon request. The
Pennsylvania Uniform Crime Reporting Act requires Penn to provide information about its security policies and procedures to students,
employees and applicants; to provide crime statistics to students and employees, and to make those statistics available to applicants and
prospective employees upon request. The information about Penn is available at:
http://www.publicsafety.upenn.edu/assets/CleryDocuments/2013AnnualSecurityFireSafetyReport.pdf or by calling the Division of Public
Safety at (215) 898-4481.
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