ODPHP Visiting Scholar Application

ODPHP
Visiting Scholar
Application

Applicant Information
Please fill out this form completely and click the 'Submit' button to save your application.
First Name
Last Name
Degrees / Credentials
Mailing Address
City
State
Zip Code
Phone Number
Alternate Phone Number
E-mail Address
Current Position
Scholar Category
Other Category (if not listed above)
Year in Program
Completion or Graduation Date
Name of Organization	(Emerging Leaders, specify home OPDIV)
Program Track (for Emerging Leaders only)
Name of Supervisor
Supervisor Telephone
Supervisor E-Mail
Rotation Information
Preferred Length of Rotation
Preferred Rotation Dates
1^stchoice 2^nd choice 3^rdchoice
ODPHP Project Areas of Interest
How did you hear about this educational opportunity?
Credentials
Statement of Interest. Write a brief statement of no more than 700 words addressing why you are interested in this educational opportunity. You may want to include: personal and professional goals for your rotation at ODPHP the subject matter area(s) you would like to focus on during your rotation prior experience and skills you will bring to projects at ODPHP

Resume or Curriculum Vitae

Provide 2 academic and/or professional references.
Reference 1
Name
Phone Number
E-mail Address
Reference 2
Name
Phone Number
E-mail Address

For more information about applying for a rotation in ODPHP, please contact:
Jayaram Srinivasan, MD, MPH, CPH
Senior Clinical Advisor, Office of Disease Prevention and Health Promotion
13th Luther L. Terry Senior Fellow in Preventive Medicine
Office of the Secretary, U.S. Department of Health and Human Services
1101 Wootton Parkway, Suite LL-100
Rockville, MD 20852
Phone: (240) 453-8268
Fax: (240) 453-8281
Email: jayaram.srinivasan@hhs.gov