Health Systems Science Academy Application

Your submission of the information below confirms that you agree to participate fully in the Health Systems Science Academy and to fulfill the requirements and expectations as listed in the introductory materials. Further, your submission indicates that you have met with your senior vice president, vice president or department chair (and division chief, if appropriate) and have discussed the time commitment and expectations involved in participating in this program, as well as the potential project.

First Name

Last Name

Department

Phone

Office Location

Mailcode

Have you applied to this program in the past?

YesNo

SVP, VP or Department Chair Name

SVP, VP or Department Chair Email

Division Chief Name

Division Chief Email

Upload your current CV here (PDF format only)

How will participating in the Health Systems Science Academy contribute to your professional goals, your department’s goals, and to the learners with whom you interact?

Describe how participation in the Academy will shape how you will contribute to your department in the future. In addition, how will what you learn in the Academy help shape the kind of teacher you will be in the future? Please include any specific knowledge and skills that you wish to acquire and how those relate to your career goals.

Why does learning about Health Systems Science interest you?

If relevant, include any specific knowledge and skills that you will bring to the Academy related to the core domains of Health Systems Science.

After meeting with your department leadership, please provide a brief description of a problem you are trying to solve, a process you would like to improve, or a curriculum you would like to develop that addresses a specific gap, need, or challenge relevant to your department or to your educational role. What evidence/data do you currently have to support that this is a problem/gap?

For example, I will develop an introductory QI module for residents within the department, or I will develop an evaluation tool for an educational activity around population health.