1. Please select which statement is true · 11/1/2018 2019 UCLA Public Health Scholars Training...

11/1/2018 2019 UCLA Public Health Scholars Training Program Application - COPY - Formstack

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Application Instructions and Program Eligibility

Welcome to the online application for the UCLA Public Health Scholars Training Program atthe UCLA Fielding School of Public Health. This program is part of the Centers for DiseaseControl and Prevention, Office of Minority Health and Health Equity’s Undergraduate PublicHealth Scholars Program (CDC CUPS). You may apply to other CDC CUPS Programs, but notethat you must apply to each program separately. The UCLA Public Health Scholars TrainingProgram encourages students and recent graduates from all backgrounds to apply.

You can download a preview of the application here.

You can save and return to the application to pick up where you left off and/or edit previousresponses until you click “Submit Form.”

1. Please select which statement is true:

By June 24, 2019, I will be enrolled as an undergraduate student in a four-year institution

(community college transfers eligible) and will have completed at least two years of undergraduate

education.

I graduated from an undergraduate degree program Spring 2018 term or later, and I have not

enrolled into a graduate program.

None of the above.

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2. Have you participated in another CDC CUPS (CDC UndergraduateScholars Programs) summer program?

Yes

No

CDC CUPS programs include: MCHC/RISE-UP (Kennedy Krieger Institute), Project IMOTEP (Morehouse), Summer PublicHealth Scholars Program (Columbia University), FPHLP (Michigan School of Public Health).

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11/1/2018 2019 UCLA Public Health Scholars Training Program Application - Formstack

https://uclapublichealthscholars.formstack.com/forms/2019_ucla_public_health_scholars_training_program_application 1/4

First Name

Middle Name

Last Name

Suffix

Applicant Information

3. Name*

4. Date of Birth*

5. Cell Phone Number*

6. Home Phone Number Powered by Formstack Create your own form ›



7. How did you find out about this program? (Check all that apply)*

UCLA Fielding School of Public Health Website

CDC Website

Information Session

Academic Advisor

Other Professor

Friend

Email Announcement

Listserv or Other Distribution List

Conference Booth

Flyer

Other:

8. Email*

Confirm 8. Email*

9. Permanent Address * Powered by Formstack Create your own form ›



City

State

ZIP Code

City

State

ZIP Code

Country

10. Current Address*

Country


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Educational Information

11. In September 2019, I will be a:*

Junior

Senior

Recent Graduate (Spring 2019)

Graduate (Winter 2018)

Graduate (Spring 2018)

12. Have you participated in another summer academic enrichment orsummer research program?*

Yes

No

16. What is the name of the college or university where you arecurrently enrolled?*




If you have already graduated, please list the college or university where you received your degree.

17. Have you attended any other colleges or universities?*

Yes

No

18. Please list all other colleges or universities you attended and theyears you attended.

19. Have you ever attended a college or university that has beendesignated as a minority serving institution?*

Yes

No

Don't know

21. What is your anticipated graduation date?*

If you have already received an undergraduate degree,please list the date you received your degree.

22. Cumulative GPA *

23. Please list your major(s):*




24. Please list your minor(s):

25. Are you a first generation college student? *

Yes

No

Don't know

Decline to state

For our program, a first-generation college student is identified as a student whose parent(s)/guardian(s)have not receiveda four-year U.S. bachelor’s degree

26. My highest educational goal is to receive a:*

Bachelor’s degree

Master’s degree in Public Health

Other Master's Degree

Professional degree (e.g., MD, JD, PharmD, DDS, DPT,DSW)

Doctoral Degree (e.g., PhD, DrPH)

Don't know

Other:

27. Please indicate the specific degree you would like to pursue. *

Please write NA if you are not sure yet.




Activities, Honors, and Awards

28. Describe your past community service, leadership, extracurricular,and/or research experiences

1,050 character maximum

29. List any achievements, such as honors or awards.






Interests

30. Did you apply to the UCLA Public Health Scholars Training Programlast year?*

Yes

No

31. Please rate your interest in the following:* 1 Not at all

interested2 3 4 5 Extremely

InterestedDon't Know

HealthDepartments

OtherGovernment

Agencies

Hospital andHealthcare

Systems

Community-Based

Organizations

ResearchInstitutions




University orAcademicSettings

Foundations

InternationalOrganizations




Biostatistics

CommunityHealth

Sciences

EnvironmentalHealth

Sciences

Epidemiology

Health Policyand

Management




Aging

Disabilities

DisasterPreparedness

Education

EnvironmentalHealth and

EnvironmentalJustice

HealthDisparities

HealthMessaging

Healthcare

Housing Powered by Formstack Create your own form ›



Homelessness

Immigration

InfectiousDiseases

Labor

Maternal andChild Health

MassIncarceration

Mental Health

MinorityHealth

Nutrition

Oral Health

PhysicalActivity

Racism

Sexual Health

SubstanceAbuse

VeterinaryPublic Health

ViolencePrevention

War/Refugees

34. Please select the group that best describes you. There is no rightanswer. The UCLA Public Health Scholars Training Program is lookingfor students at all stages of public health interest and training(introductory to advanced):*

Group 1: I have little to no exposure to the field of public health or health disparities

Group 2: I am interested in another health related discipline (ie MD, RN, Social Work, etc)

Group 3: I am currently pursuing public health/health

35. Please rate yourself on the following:* Powered by Formstack Create your own form ›



y g 1 None 2 3 4 5 Excellent

Your currentunderstanding of

public health

Your currentexperience

working withcommunity-based

organizations

Your currentexperience

volunteering withcommunity-based

organizations

Your currentleadership

abilities

Your currentunderstanding ofhealth inequities

Your current skillsin cross-culturalor multi-cultural

settings

Your currentability to

communicate inwriting and orally

with culturalproficiency

Your currentability to identify

communityresources and

assets

Your ability towork in a team

Yourunderstanding ofthe role of public

healthprofessionals





Application Essays

36. How will participating in the UCLA Public Health Scholars TrainingProgram help your future education and/or career goals?


37. Describe a time when you demonstrated leadership ability.


38. In your opinion, what is a major health or public health problemfacing your community? Why is it important to address the problem,and what is one way the problem could be addressed?



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Demographic Information

We encourage applicants from all backgrounds to apply for our program. Your answersto these questions will help us understand our applicant pool.

39. What is your gender?*

Male

Female

Transgender

Decline to State

Other:

40. Do you identify as straight or heterosexual, as gay, lesbian orhomosexual, or bisexual?*

Heterosexual

Gay, lesbian, or homosexual Powered by Formstack Create your own form ›



Bisexual

Not sexual/celibate/none

Other

Don't know

Decline to State

41. Are you Latino or Hispanic?*

Yes

No

Decline to state

Don't know

42. How would you describe yourself?*

Asian

American Indian or Alaska Native

Black or African American

Native Hawaiian

Other Pacific Islander

White

Decline to State

Don't know Powered by Formstack Create your own form ›



Other:

43. What is your primary language?*

English

Asian Indian Languages

Cantonese

Korean

Mandarin

Russian

Spanish

Vietnamese

Tagalog

Decline to state

Don't know

Other:

Check all that apply

45. We are interested in your own opinion of how well you speakEnglish. Please select the option that describes how well you speakEnglish: *

Very Well Powered by Formstack Create your own form ›



Well

Not well

Not at all

Decline to state

46. Were you born in the United States?*

Yes

No

Decline to state

Don't know

47. Was your mother/guardian 1 born in the United States?*

Yes

No

Decline to state

Don't know

48. Was your father/guardian 2 born in the United States?*

Yes

No

Decline to state

Don't know Powered by Formstack Create your own form ›



49. Please select the option that best describes your citizenship status*

U.S. Citizen

U.S. National

Permanent Resident

Temporary Resident

Non Resident

Other

Decline to state

50. Do you have a disability? *

Yes, I have a disability (or previously had a disability)

No, I do not have a disability

Decline to state

Don't know

For additional information on what constitutes a disability, please visit: https://www.cae.ucla.edu/What-constitutes-a-disability

51. What is your household’s annual income from all sources beforetaxes? (If you are still claimed as a dependent by a parent or guardian,please answer the question considering the household income of theperson who claims you as a dependent).*

$10,000 or less

$10,001-$20,000




$20,001-$30,000

$30,001-$40,000

$40,001-$50,000

$50,001-$60,000

$60,001-$70,000

$70,001-$80,000

$80,001-$90,000

$90,001-$100,000

$100,001-$135,000

More than $135,000

Decline to state

Don't know

52. Including yourself, how many people living in the household aresupported by the total household income?*

If you are still claimed as a dependent by a parent or guardian, please answer the question considering the household of theperson who claims you as a dependent.

53. Have you ever received free or reduced price lunch benefits?*

Yes

No

Decline to state Powered by Formstack Create your own form ›



Don't know

For additional information, visit: https://www.fns.usda.gov/nslp/national-school-lunch-program-nslp

54. Are you eligible for a Pell Grant?*

Yes

No

Decline to state

Don't know

For additional information, visit: https://studentaid.ed.gov/sa/types/grants-scholarships/pell

55. What is your Expected Family Contribution (EFC)? (If you do notknow or decline to state, please skip this question)

This information can be found from your FAFSA Student Aid Report.

56. What is the type of geographic area where you were raised?*

Urban (population >1,000,000)

Large City (population 100,000 to 1,000,000)

Mid-Size City (population 50,000 to 99,999)

Large Town (population 10,000 to 49,999)

Small Town (population 2,500 to 9,999)

Isolated Rural (population < 2,500)

Decline to State

Don't know

If you were raised in multiple geographic areas, please answer the question considering the geographic area you spent themajority of time. Powered by Formstack Create your own form ›



57. Please indicate if the following statements apply to you.* Yes No Don't know Decline to state

I graduated from ahigh school from

which a lowpercentage of seniorsreceive a high school

diploma.

I graduated from ahigh school at whichmany of the enrolledstudents are eligiblefor free or reduced

price lunches.

I am from a familythat receives public

assistance (e.g., Aid toFamilies with

Dependent Children,food stamps,

Medicaid, publichousing) or I receive

public assistance.

I am from a familythat lives in an area

that is designated as aHealth ProfessionalShortage Area or a

MedicallyUnderserved Area.

I participated in anacademic enrichment

program funded inwhole or in part by the

Health CareersOpportunity Program.

I received analternative high

school diploma, suchas AHS or GED.

I am from a schooldistrict where 50% orless of graduates goto college or wherecollege education is

not encouraged.




58. Please indicate your United States Military status:*

On Active Duty

Veteran

Member of Reserve or National Guard

Military Dependent

Not a Member of the Military

Other

Decline to state


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Documents

59. Please upload your resume or curriculum vitae.*

No file chosen

File uploads may not work on some mobile devices.Only PDF files are supported.

60. Please upload an unofficial undergraduate transcript.*

No file chosen

File uploads may not work on some mobile devices.Only PDF files are supported. Please ensure the transcript includes your name and the school name. Official transcripts arenot required as part of the application process, but will be required upon acceptance into the program.


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First Name

Middle Name (optional)

Recommendations

Recommenders are to submit a letter of recommendation online via Formstack. They areautomatically sent a link to submit their letter of recommendation once the "Submit Form" isclicked. If you would like to provide the link in advance, please share the following link:https://UCLAPublicHealthScholars.formstack.com/forms/letter_of_recommendation.

You must list contact information for the two (2) individuals who will providerecommendations in order to submit your application. Recommendations should be fromacademic advisors, professors, supervisors, mentors, or anyone else familiar with youracademic and/or professional ability.

Both recommendations must be received by January 31, 2019. It is your sole responsibilityto ensure your recommenders submit their letters by the deadline.

61. Please provide the contact information for your first recommendation:

Name




Last Name

Suffix (optional)

First Name

Middle Name (optional)

Position Title

Institution/Organization

Email

Confirm Email*

Phone Number

Relationship to Applicant

62. Please provide the contact information for your second recommendation

Name




Last Name

Suffix (optional)

Position Title

Institution/Organization

Email

Confirm Email*

Phone Number

Relationship to Applicant

63. I hereby give permission for the UCLA Public Health ScholarsTraining Program to contact the recommenders listed in myapplication. I understand that my recommenders may be contactedeither to verify the information provided and/or to further clarifyinformation provided, and I hereby give permission for the UCLA PublicHealth Scholars Training Program to do so. I also waive my right toaccess the recommendations provided by my recommenders. By




[clear]

signing my name in the signature area below, I am signing thisapplication electronically.

Use your mouse or finger to draw your signature above


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Program Agreements

64. We are interested in understanding the need for summer publichealth programs. Would you be willing to be contacted to help usevaluate the need for these opportunities?*

Yes

No

65. I understand that acceptance into the program does not guaranteethat I will receive a stipend. I will need to meet the eligibility criteria inorder to receive a stipend. Eligibility criteria for stipends and anyrelated restrictions will be discussed with applicants upon acceptanceinto the program.*

Yes, I understand and agree to the above statements regarding stipends.

No, I do not understand or do not agree to the above statements regarding stipends.

66. I understand that if I am accepted into and enroll in this program, I commit to thefollowing:




(Please initial next to each statement to indicate you agree)

Being present and available in Los Angeles from June 23 - August 16,2019 to participate in the UCLA Public Health Scholars TrainingProgram. This includes not being enrolled in any other programs orsummer school during this time.*

Willingness to attend events on Wednesday evenings and occasionalweekends.*

Willingness to participate in remote activities related to the program inlate Summer and Fall 2019. *

Living in housing at UCLA, which will be provided by the UCLA PublicHealth Scholars Training Program. *

Exceptions to campus housing will be considered on a case by case basis once scholars are accepted into the program.

Acting in a professional manner and complying with my internshiprequirements.*

Attending all UCLA Public Health Scholars Training Program meetings,workshops, and events.*

Completing all of my internship hours as required by the program.* Powered by Formstack Create your own form ›



Participating as requested in community activities for the project towhich I am assigned or in any of the UCLA Public Health ScholarsTraining Program activities.*

Submitting materials and documentation as required by the UCLAPublic Health Scholars Training Program in a timely manner.*

Attending a trip to the Centers for Disease Control and Prevention inAtlanta, Georgia with Public Health Scholars from other programsacross the nation (Expenses covered by the program).*

Meeting the educational eligibility requirements, which include either(1) being enrolled as an undergraduate student in a four-yearinstitution (community college transfers eligible) and completed atleast two years of undergraduate education by June 23, 2019 OR (2)having graduated from an undergraduate degree program Spring2018 term or later, and not accepted into a graduate program.*

67. I hereby attest that I have personally completed this applicationand the information contained within is complete and accurate to myknowledge. I understand that participation in this program requiressubmission of all required documents, an in-person interview, beingselected as one of the students to participate in the UCLA Public HealthScholars Training Program, and enrollment in the program. Bysubmitting this application, I understand that the information I providemay be summarized and shared with the federal agencies and other Powered by Formstack Create your own form ›



[clear]

Submit Form

organizations that support the work of the UCLA Public Health ScholarsTraining Program. By signing my name in the signature box below, Iam signing this application electronically.*

Use your mouse or finger to draw your signature above

Carefully review your application for accuracy prior to submitting your application.

The UCLA Public Health Scholars Training Program will not make revisions to yourapplication once it is submitted.

Applications must be submitted by January 31st, 2019 to be considered.

To submit your application, click "Submit Form".


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