2019 Psychiatric Research Fellowship Application Form

AMERICAN PSYCHIATRIC ASSOCIATION FOUNDATION
Psychiatric Research Fellowship Application Form

PARTICIPATION IS LIMITED TO ONLY ONE FELLOWSHIP PROGRAM AT A TIME.

1) applications must be completed and submitted in one sitting; there is no option to start then finish later and
2) applications must be submitted on a PC or laptop; smart phones or tablets are not suitable.

1. APA Membership #: (NOTE: APA membership is required at the time of fellowship matriculation)

2. Current PGY Level: *This question is required. This question requires a valid number format.

3. Projected PGY Level by July 30, 2019: *This question is required. This question requires a valid number format.

BIOGRAPHICAL/DEMOGRAPHIC INFORMATION

4. Applicant Information: *This question is required.

First Name

Last Name

Level of Education (i.e., M.D., M.P.H)

Street Address

Apt/Suite/Office

City

State (Initials)

Zip

Country

5. Preferred Phone: *This question is required.

6. Preferred Email (to be used to notify applicant): *This question is required. This question requires a valid email address.

7. Gender: *This question is required.

8. Country of Citizenship: *This question is required.

If not a U.S. citizen, are you a permanent visa resident?

9. Ethnic/Race: (Required for Psychiatric Research Fellowship, SAMHSA, SAMHSA Substance Abuse, and Diversity Leadership programs)
*This question is required.

10. Are you Spanish/Hispanic/Latino?
*This question is required.

Current Training Program Information

11. Name of Institution: *This question is required.

12. Institution Address: *This question is required.

13. General or Sub-specialty Training: *This question is required.

14. Date From: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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15. Date To: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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16. Current Training Director Name: *This question is required.

17. Current Training Director Address: *This question is required.

18. Current Training Director Email: *This question is required. This question requires a valid email address.

As of July of the year for which you are applying: (if different from above)

19. Future Training Director Name: *This question is required.

20. Future Training Director Address: *This question is required.

21. Future Training Director Email: *This question is required. This question requires a valid email address.

PROFESSIONAL AND RESEARCH INTERESTS

22. Please specify your professional interest areas (i.e., Interest in working in academia).

1.
2.
3.

23. Please specify your research interest areas.

1.
2.
3.

OTHER INFORMATION

24. Have you ever applied to an APA resident fellowship? *This question is required.

If so, list program name and year applied

25. Have you ever received an APA resident fellowship? *This question is required.

If so, list program name and year received:

26. Do you plan to work with minority groups and/or underserved persons after training is complete? *This question is required.

If yes, please specify in a brief statement, limited to 500 characters:

27. How did you learn about this program? *This question is required.

Your uploads must fully meet all application requirements. Click link to return to specific requirements.

28. Curriculum Vitae (50MB limit)
PDF naming structure: (FirstName-LastName-CV.pdf) PDF naming example: John-Smith-CV.pdf *This question is required.

File: {{filename}} delete

29. Nominee's Personal Statement (50MB limit)
PDF naming structure: (FirstName-LastName-NPS.pdf) PDF naming example: John-Smith-NPS.pdf *This question is required.

File: {{filename}} delete

30. Nominee's Preceptor's Statement (50MB limit)
PDF naming structure: (FirstName-LastName-NPRECS.pdf) PDF naming example: John-Smith-NPRECS.pdf *This question is required.

File: {{filename}} delete

31. Letter from the Nominee's Department Chair (50MB limit)
PDF naming structure: (FirstName-LastName-LTRNDC.pdf) PDF naming example: John-Smith-LTRNDC.pdf *This question is required.

File: {{filename}} delete

32. Date of application submission (Today's date): *This question is required. This question requires a valid date format of MM/DD/YYYY.

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All materials must be received together by 12 midnight Eastern Standard Time, January 30, 2019.

Incomplete documentation upload may be grounds to reject the entire application.