Application for Admission Master of Health Sciences in Clinical Leadership Program Duke University School of Medicine

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Application for Admission

Master of Health Sciences in Clinical Leadership Program

Duke University School of Medicine

Duke University is an Equal Opportunity institution. Duke University offers equal opportunity to all qualified applicants without regard to race, color, national or ethnic origin, handicap, sexual orientation or preference, sex, or age. The questions concerning race, sex, and national origin on the application form are for the purpose of meeting federal reporting requirements and are optional.

Note: See “Information for Applicants” for complete application information. Mail this form to the Clinical Leadership Program, Department of Community and Family Medicine, Box 104425, Duke University Medical Center, Durham, NC 27710.

1. ___________________________________________________________________________________

Last or Family Name First Middle

Social Security Number ________ - ______- __________ Gender: Female _____ Male ____

2. Country of citizenship ______________________________________________________________

If not US Citizen, indicate type of visa you hold ___________________________________________

3. Date of Birth __ __ - __ __ - __ __ Place of Birth _______________________________

Month Day Year

4. Race/National origin ___ White (not Hispanic) ___ Asian or Pacific Islander (check one) ___ Black (not Hispanic) ___ Hispanic

___ American Indian or Alaskan Native

5. E-mail address ______________________________________________________________________

6. Home Telephone Number (________) ________________ and Home Mailing Address

___________________________________________________________________________________

Number and Street City State Zip Code

7. DUMC Affiliation (if any) _________________________________________ DUMC Box _________

Department Division

8. Work Telephone Number (________) ________________ and Mailing Address (if not DUMC) ____________________________________________________________________________________

Number and Street City State Zip Code

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*Official transcripts from all post-secondary/graduate institutions attended must be sent to the Clinical Leadership Program directly by the institution. Personal copies can not be accepted.

10. List in chronological order all post-secondary colleges and universities attended:

From Through Major Degree or Institution Location Mo/Yr Mo/Yr Field Diploma

____________________________________________________________________________________

__________________________________________________________________________________

11. List in chronological order all residency, or fellowship training institutions attended:

From Through

Institution Location Mo/Yr Mo/Yr Field

__________________________________________________________________________________

Do you have specialty boards or certifications? ___No ___Yes (please specify) _________________

12. Beginning with your current or most recent position, list the last three positions that you have held for six months or longer:

From Through

Employer Location Mo/Yr Mo/Yr Position

__________________________________________________________________________________

13.

Do you wish to be considered for admission as a degree candidate or as a non-degree

participant? (Check one)

_ Degree candidate _ Non-degree participant

14. Have you taken the General Aptitude Test (GRE) which is required of all applicants who do not have a graduate degree?

___ Yes: Date _____-_____ ___ No: Date Scheduled _____-_____ ___ N/A

Month Year Month Year

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15. List three individuals who will supply letters of evaluation, preferably individuals not all from the same organization: (Use forms provided.)

Name Position Institution

__________________________________________________________________________________

16. List any honors, distinctions, prizes or scholarships received:

__________________________________________________________________________________

17. If you have published papers, list up to three (journal, volume, page numbers and year) and enclose reprints:

__________________________________________________________________________________

18. Write a brief statement describing your clinical experience:

__________________________________________________________________________________

___________________________________________________________________________________

_________________________________________________________________________________

_____________________________________________________________________________________

____________________________________________________________________________________

___________________________________________________________________________________

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19. Write a brief statement describing your administrative experience (program administration, strategic planning, supervision, budget preparation/management, etc.)

__________________________________________________________________________________

20. Write a brief statement describing your most challenging team experience. What did you learn from this experience?

__________________________________________________________________________________

___________________________________________________________________________________

__________________________________________________________________________________

21. Write a brief statement stating your career goals and the place of this program in accomplishing those goals:

__________________________________________________________________________________

___________________________________________________________________________________

__________________________________________________________________________________

I hereby certify that the information given by me in this application and attached statements is complete and correct to the best of my knowledge.

______________________________________________ ______________________________

Signature Date

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Information for Applicants

PROGRAM OPTIONS

Duke’s Master of Health Sciences in Clinical Leadership Program (MHS-CL) offers clinicians an opportunity to expand their knowledge base and develop leadership skills.

The MHS-CL’s online, distance-based format is designed for professional clinicians. Classes are scheduled to accommodate the demands of clinical schedules. Classes make use of the students’ experience and students can use their workplaces as “laboratories” in which to practice their new skills.

The program requires attendance at 3-4 day, on-campus sessions in Durham, NC at the beginning of each term. . On-campus dates are scheduled well in advance. .

ADMISSION

To be considered for admission, candidates must have all application materials submitted by the deadline for the semester for which they wish to begin the program. Materials received after the application deadline will automatically be considered for the following semester. Application deadlines are:

May 1 – To be considered for the fall semester

September 1 – To be considered for the spring semester February 1 – To be considered for the summer semester

Applicants seeking admission as a degree candidate or as a non-degree auditing student should submit the application form and provide the following supporting documents. Non-degree candidates are not required to complete an admission committee interview.

Transcripts.

An official transcript from each post-secondary institution attended must be sent to the Clinical Leadership Program directly by the institution. Personal copies are not acceptable.

Letters of Evaluation.

Three letters are required. One letter must come from someone who can testify to your clinical experience and one letter must come from someone who can testify to your administrative experience. All letters should be written by persons who are qualified to testify to your capacity for graduate work. Evaluation forms are provided; they should be mailed to the Clinical Leadership Program directly by the evaluators.

Test Scores.

Applicants who do not possess a graduate degree are required to provide scores on the Graduate Record Examination (GRE) General (Aptitude) Test. The scores must not be more than five years old and they must be mailed to the Clinical Leadership Program from the Educational Testing Service.

Admissions Interview.

Applicant finalists will be required to complete an admissions interview.

APPLICATION FEE

The non-refundable $100 application fee ($50 for non-degree candidates) must be included with the application for it to be considered complete. Checks should be made payable to “Clinical Leadership Program.”

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TUITION

Tuition for the degree program is approximately $39,600. Students are billed each semester. Once a student is admitted to the program, a non-refundable tuition deposit of $500 is required within ten days of admission to reserve a spot in the class. This amount is applied to the first tuition payment.

Some students fund their own education, and others are sponsored entirely or in part by their employer. For those who are self-funded, Duke’s School of Medicine Office of Financial Aid offers resources regarding loans and scholarships. We encourage you to contact them as soon as possible to begin that process.

FOR MORE INFORMATION

Visit our website: http://clinical-leadership.mc.duke.edu or contact Claudia J. Graham at 919.681.5724 or [email protected]

Division of Community Health

Department of Community & Family Medicine DUMC Box 104425

Durham, NC 27710 919-681-5724

Application for Admission Master of Health Sciences in Clinical Leadership Program Duke University School of Medicine