Instructions for Completing the Application Form for the
Doctoral Program in Epidemiology and Translational Science

PLEASE COPY AND SAVE THE APPLICATION FORM ON YOUR COMPUTER BEFORE
COMPLETING IT.

BEGIN TYPING IN THE FIRST SHADED BOX.

USE THE TAB KEY (NOT THE ENTER OR RETURN KEY) TO MOVE TO THE NEXT SHADED BOX.

YOU MAY ALSO USE THE MOUSE TO MOVE TO ANY SHADED BOX AT ANY POINT.

USE THE MOUSE TO CLICK ON THE CHECK-BOXES.
Application Check List

Application Form for the Doctoral Program in Epidemiology and Translational Science
(Submit to David Swanson at the address below. Please also email to dswanson@psg.ucsf.edu)

Official transcripts from all institutions attended beyond high school
(Submit in sealed envelope with official stamp/signature of the institution to David Swanson at the address below)

Three letters of recommendation
(References must send the letters of recommendation directly to David Swanson in a sealed envelope to the address below)

Official Test of English as a Foreign Language (TOEFL) scores. Request that the TOEFL/TSE services (www.toefl.org)
send official score report to UCSF. Use recipient code 4840. TOEFL is required of applicants who hold an advanced degree
from a non-English speaking country.
Send materials to:
David Swanson
Doctoral Program in Epidemiology and Translational Science
University of California, San Francisco
185 Berry St, Suite 5700
San Francisco, CA 94107
415-514-8000 (telephone)
415-514-8150 (fax)
For Administrative Use Only: Dates Materials Received
Ref 1 _________
Ref 2 _________
Ref 3 _________
Initial Application:
Undergraduate Transcript
____________
Professional School Transcript
____________
Application Complete
v. 5/5/10
____________
Application Form
Doctoral Program in Epidemiology and Translational Science
Current Information:
Male
Last Name
First Name
Middle Initial
Female
/
Gender (check)
(
Home Address
City
Office Address
State
(
UCSF Box #
Zip Code
City
Electronic Mail Address
Current Position/Title (e.g., Fellow)
)
-
(
Ext.
Institution
)
-
Telephone Number
State
Office Telephone Number
/
Date of Birth
)
Zip Code
-
Fax Number
School (e.g., Medicine, Dentistry,
Pharmacy, Nursing)
Department
Ethnicity:
Puerto Rican
Chicano/Mexican American
Latino/Latin American
American Indian/Native American
White/Caucasian
Division (if applicable)
East Indian/Pakistani
Polynesian/Pacific Islander
African American
Filipino/Filipino American
Chinese/Chinese American
Degree
(e.g., MD)
Country of Citizenship
Japanese/Japanese American
Korean/Korean American
Thai/Other Asian
Vietnamese/Vietnamese American
Other (please specify):
Education: list all undergraduate, graduate, and professional schools attended in chronological order.
1.
Institution
Dates of Attendance
Location
Major
Degree and Graduation Date
2.
Institution
Dates of Attendance
Location
Major
Degree and Graduation Date
3.
Institution
Dates of Attendance
Location
Major
Degree and Graduation Date
4.
Institution
Dates of Attendance
Location
Major
Degree and Graduation Date
5.
Institution
Dates of Attendance
Location
Major
Degree and Graduation Date
Post Graduate Training: include internships, residencies, fellowships, and other appointments.
1.
Position
Institution
Department
School (e.g., Medicine, Dentistry)
Division
2.
Position
Institution
Department
School (e.g., Medicine, Dentistry)
Division
3.
Position
Institution
Department
School (e.g., Medicine, Dentistry)
Division
4.
Position
Department
Institution
School (e.g., Medicine, Dentistry)
Division
Academic Honors, Honorary Societies, and Awards:
Date
Title
Date
Title
Date
Title
Date
Title
Research Experience: include major clinical and laboratory research experiences (full and part-time).
1.
Position
Institution
Project Title
Dates
2.
Position
Institution
Project Title
Dates
3.
Position
Institution
Project Title
Dates
4.
Position
Institution
Project Title
Dates
5.
Position
Institution
Project Title
Dates
Board Certification Status: include Specialties (e.g., Internal Medicine, Pediatrics) and Sub-Specialties (e.g.,
Infection Diseases, Cardiology)
Are you board certified or eligible? YES
NO
If yes, specify the board(s) 1)
2)
1)
Have you taken the exam? YES
Status:
2)
exam taken, awaiting report
Have you taken the exam? YES
Status:
NO
failed exam
board certified - date:
/
/
failed exam
board certified - date:
/
/
NO
exam taken, awaiting report
Publications:
Use the provided optional additional information page if publications exceed one page.
Objectives:
Please describe your reasons for interest in the program. Include your objectives, clinical and research
interests and goals, and how acceptance into the program can help you accomplish these. Please limit your
response to this page.
Optional Additional Information:
Please use the following space to tell us anything else you would like us to know about your background,
experience, or objectives. Please limit to one page.
References:
List three individuals whom you have asked to send letters of reference. One should be the Director of your
current training program (if you are a fellow), your Division Chief or Department Chairperson (if you are a
faculty member), your Faculty Advisor (if you are a pre-doctoral student), or equivalent. Please provide
each reference with one of the enclosed recommendation forms.
1.
Name
Position/Title
Address
Address
2.
Name
Position/Title
Address
Address
3.
Name
Position/Title
Address
Address
Signature (please sign the hard-copy version of this application): ___________________________
Date of Application: / /
In addition to this application form and three letters of references, please arrange to have official sealed
transcripts from all undergraduate, graduate, and professional schools sent to the address below. If applicable,
please arrange to have your official TOEFL scores sent to UCSF. Use recipient code 4840.
Please send all materials by mail to:
Robert A. Hiatt, MD, PhD
Program Director
c/o David Swanson
Doctoral Program in Epidemiology and Translational Science
University of California, San Francisco
185 Berry St, Suite 5700 UCSF Box 0560
San Francisco, CA 94107
Telephone: 415-514-8000
Fax: 415-514-8150
Please also send a copy of this application form, as an email attachment, to dswanson@psg.ucsf.edu
REFERENCE REPORT
Doctoral Program
in Epidemiology and Translational Science
This section is to be completed by the applicant.
Please type or print in ink.
Last Name of Applicant
First Name
Middle Initial
I waive the right to read this letter at a later time.
I do not waive the right to read this letter.
To the Reference
The above-named applicant for admission into the Doctoral Program in Epidemiology and Translational
Science at the University of California, San Francisco School of Medicine has identified you as one of his/her
references. The completed reference form should be returned to:
Robert A. Hiatt, MD, PhD
Program Director
c/o David Swanson
Doctoral Program in Epidemiology and Translational Science
University of California, San Francisco
185 Berry St, Suite 5700 UCSF Box 0560
San Francisco, CA 94107
Please rate the applicant by circling the appropriate number that most nearly represents your opinion of the
applicant in comparison with other individuals with the same training and experience.
Initiative
Demonstrated skill at research
Integrity
Judgment
Demonstrated originality
Leadership capacity
Demonstrated productivity
Ability to communicate (written)
Ability to communicate (spoken)
Overall evaluation
Unable to
Judge
0
0
0
0
0
0
0
0
0
0
Poor
Fair
Good
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
Outstanding
4
4
4
4
4
4
4
4
4
4
In a separate letter, please elaborate on the applicant’s performance as you indicated above. If possible, please
describe specific examples that would illustrate your evaluation.
Name of reference
Title
Signature of reference
Institution
Telephone Number
REFERENCE REPORT
Doctoral Program
in Epidemiology and Translational Science
This section is to be completed by the applicant.
Please type or print in ink.
Last Name of Applicant
First Name
Middle Initial
I waive the right to read this letter at a later time.
I do not waive the right to read this letter.
To the Reference
The above-named applicant for admission into the Doctoral Program in Epidemiology and Translational
Science at the University of California, San Francisco School of Medicine has identified you as one of his/her
references. The completed reference form should be returned to:
Robert A. Hiatt, MD, PhD
Program Director
c/o David Swanson
Doctoral Program in Epidemiology and Translational Science
University of California, San Francisco
185 Berry St, Suite 5700 UCSF Box 0560
San Francisco, CA 94107
Please rate the applicant by circling the appropriate number that most nearly represents your opinion of the
applicant in comparison with other individuals with the same training and experience.
Initiative
Demonstrated skill at research
Integrity
Judgment
Demonstrated originality
Leadership capacity
Demonstrated productivity
Ability to communicate (written)
Ability to communicate (spoken)
Overall evaluation
Unable to
Judge
0
0
0
0
0
0
0
0
0
0
Poor
Fair
Good
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
Outstanding
4
4
4
4
4
4
4
4
4
4
In a separate letter, please elaborate on the applicant’s performance as you indicated above. If possible, please
describe specific examples that would illustrate your evaluation.
Name of reference
Title
Signature of reference
Institution
Telephone Number
REFERENCE REPORT
Doctoral Program
in Epidemiology and Translational Science
This section is to be completed by the applicant.
Please type or print in ink.
Last Name of Applicant
First Name
Middle Initial
I waive the right to read this letter at a later time.
I do not waive the right to read this letter.
To the Reference
The above-named applicant for admission into the Doctoral Program in Epidemiology and Translational
Science at the University of California, San Francisco School of Medicine has identified you as one of his/her
references. The completed reference form should be returned to:
Robert A. Hiatt, MD, PhD
Program Director
c/o David Swanson
Doctoral Program in Epidemiology and Translational Science
University of California, San Francisco
185 Berry St, Suite 5700 UCSF Box 0560
San Francisco, CA 94107
Please rate the applicant by circling the appropriate number that most nearly represents your opinion of the
applicant in comparison with other individuals with the same training and experience.
Initiative
Demonstrated skill at research
Integrity
Judgment
Demonstrated originality
Leadership capacity
Demonstrated productivity
Ability to communicate (written)
Ability to communicate (spoken)
Overall evaluation
Unable to
Judge
0
0
0
0
0
0
0
0
0
0
Poor
Fair
Good
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
Outstanding
4
4
4
4
4
4
4
4
4
4
In a separate letter, please elaborate on the applicant’s performance as you indicated above. If possible, please
describe specific examples that would illustrate your evaluation.
Name of reference
Title
Signature of reference
Institution
Telephone Number