ADMINISTRATIVE FELLOWSHIP APPLICATION
Please complete this application form and submit it with your application packet.
Name: _______________________________________________________________
Address: _____________________________________________________________
_____________________________________________________________________
School Phone Number: __________________________________________________
Permanent Phone Number: _______________________________________________
E-mail: _______________________________________________________________
DOB: ______________________ SSN: __________________________
GRADUATE SCHOOL INFORMATION:
Graduate School Program and Department: __________________________________
Specific Degree: ________________________________________________________
Address: ______________________________________________________________
________________________________________________________________
Phone Number of Program Director: ________________________________________
Fax Number: __________________________________________________________
How Did You Hear About Us? __ Graduate Program __ ACHE __ Friend/Colleague __
Website __ Other: ______________________________________________
EMPLOYMENT INFORMATION (if applicable):
Employer: _____________________________________________________________
Applicant Position/Title: __________________________________________________
Address: ______________________________________________________________
Phone Number: ________________________ Fax Number: _____________________
ESSAY QUESTIONS:
Please respond to both essay questions. Each response should be no longer than one
page. Essays that exceed one page will not be considered.
Topic 1: Durham Regional Hospital has served the Durham community in its current
location for approximately 30 years. In 1998, Durham Regional joined the Duke
University Health System. Discuss the importance of community hospitals, and describe
the unique opportunities and challenges that exist for community hospitals as part of a
large health system. In addition, please discuss why a community hospital fellowship is
the ideal opportunity for you and why Durham Regional Hospital is the ideal place to do
such a fellowship.
Topic 2: How do you define diversity and cultural competence and its role in driving
high performance in care delivery?
STATEMENT OF GOALS AND OBJECTIVES:
Please address the following questions regarding your fellowship objectives and career
goals. Your statement should not exceed 500 words.
• Why did you choose healthcare management as career?
• What are your short-term and long-term career goals?
• All healthcare administrators want to have a positive impact on the healthcare
industry. What is your greatest strength, and how would you channel that
strength to have a positive impact on the healthcare industry?
OPTIONAL: Please check all that apply.
Used Only for Federal Reporting Requirements.
__ Female __ White __ Am. Indian/Alaskan Native __ Hispanic __ Veteran __ Male __
Black __ Asian/Pacific Islander __ Handicapped __ Disabled Veteran
ENCLOSURE CHECKLIST:
• Application Form
• Current Resume
• Cover Letter
• Graduate School Transcript (1st year only)
• Academic Recommendation
• Professional Recommendation
• Two One-Page Essays
• Statement of Goals and Objectives
Please mail this completed application form with enclosures listed above to:
Durham Regional Hospital
Duke University Health System
Attn: Lindsay Krcelic, Administrative Fellow
3643 North Roxboro Road
Durham, NC 27704