13. Current 12. Current School Major(s)/Field(s) of Study One 14. How many years of your 15. Enrollment Month Two Date: current academic program will you have completed by Three Year May 2017? Four High School Diploma BA BS 17. Prior academic 16. Prior academic MD major(s)/fields of degree/s PhD/DrPH study: MPH MA Other (specify) Cameroon 18. While the final countries for 2017 have not The Dominican Republic yet been finalized, they will likely include the five listed here (and possibly additional Kazakhstan locations). Please indicate your preference Kenya for location by ranking them on a scale of 1-5. (1=1st choice; 2=2nd choice; 3=3rd Kyrgyzstan choice, etc. If no preference, check the Swaziland “no preference” row. No preference Spoken: Language 1 19. Language proficiency. Please list languages Written: in addition to English and indicate your Spoken: level of spoken and written proficiency. Language 2 Written: (e.g., fluent, conversant, intermediate, Spoken: beginning) Language 3 Written: 20. Describe prior research experience, if any. 21. Describe prior global health experience, if any.
12. Current School 13. Current Major(s)/Field(s) of Study 14. How many years of your current academic program will you have completed by May 2017? One 15. Enrollment Date: Month Two Three Year Four 16. Prior academic degree/s High School Diploma 17. Prior academic major(s)/fields of study: BA BS MD PhD/DrPH MPH MA Other (specify) 18. While the final countries for 2017 have not yet been finalized, they will likely include the five listed here (and possibly additional locations). Please indicate your preference for location by ranking them on a scale of 1-5. (1=1st choice; 2=2nd choice; 3=3rd choice, etc. If no preference, check the “no preference” row. Cameroon The Dominican Republic Kazakhstan Kenya Kyrgyzstan Swaziland No preference 19. Language proficiency. Please list languages in addition to English and indicate your level of spoken and written proficiency. (e.g., fluent, conversant, intermediate, beginning) Language 1 Spoken: Written: Language 2 Spoken: Written: Language 3 Spoken: Written: 20. Describe prior research experience, if any. 21. Describe prior global health experience, if any.
Program_Application_-_2017_MHIRT_Fellowship.docx