2020 Nutrition Outreach Fellowship
Application Form

The PA Foundation invites practicing PAs to apply for an exclusive opportunity to build upon their knowledge of nutrition as it relates to patient care utilizing AAPA resources and special training, and to employ that knowledge in practice and in community outreach efforts.

Everyone can benefit from greater knowledge of nutrition and how it impacts health. The idea behind the Nutrition Outreach Fellowship is to provide a way for PAs, especially those with an interest in community leadership, to receive special training and resources on nutrition to both enhance their clinical practice and to give back to the community at large.

If selected, Fellows will be required to attend an in-person Fellows training currently scheduled for June 15-17, 2020, in Alexandria, VA (expenses covered). Please note that due to the evolving COVID-19 situation and related travel restrictions, this date is subject to change.

This program is supported by Abbott Nutrition.

A note for planning purposes: You will be required to upload a letter of recommendation as part of this application form.

Applicant Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Employer: *

Job Title: *

Academic Credentials: *

Certifications: *

Professional Affiliations: *

What specialty of medicine do you currently practice in? *

Have you practiced in other specialties previously? *

Yes

No

If yes, what specialties? *

Short Answer Questions

Please provide your responses to the following questions in no more than 200 words.

What is your experience helping patients achieve nutrition-related goals? *

0/200 words

Which of the following do you have experience with in connection with nutrition? Select all that apply. *

Prevention and management of type 2 diabetes

Healthy aging

Enhanced Recovery After Surgery (ERAS)

Please briefly explain. *

0/150 words

List three strategies you use to help patients meet nutrition goals. * 🛈

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Do you use outside nutrition tools/resources to encourage patients? *

Yes

No

Which tools/resources do you use? *

0/50 words

Why do you want to become a Nutrition Health Outreach Fellow? *

0/200 words

Please provide a description of your experiences in adult instruction that would qualify you as a strong candidate to be an effective presenter of the Nutrition Health Outreach Fellowship materials (i.e. group facilitation, teaching, etc.). Please provide time frames for any relevant experience. *

0/200 words

What other skills or experiences do you have that you believe will support your success as a Nutrition Outreach Fellow? *

0/200 words

Please list up to three examples of how you have effectively networked with organizations, local services or other partners within your community to support an initiative (i.e. public education initiative, community event, volunteering, etc.). * 🛈

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Please describe your plan to implement this program in the next year. Be sure to include information about how you plan to promote your presentation, who you might partner with, and what audiences you plan to target. *

0/200 words

What are some potential barriers you may face when trying to implement your above strategies? *

0/200 words

Self-Assessment

Please rate yourself on the following items using the scale provided below.

I am comfortable presenting in front of groups of up to 50 people. *

I am familiar with use of PowerPoint and a remote slide advancer. *

I am comfortable adhering to a set curriculum of objectives, required talking points, and activities. *

I am ready and able to give adequate time to work on the presentation and meet the program commitment. *

I am willing and able to spend up to 4 hours preparing for, traveling to/from, and delivering each presentation. *

I am confident that I can plan and deliver training to a minimum of 100 community members and 100 healthcare peers (with coordination/logistical support from PA Foundation program staff) over the course of the fellowship year. *

I am passionate about teaching the public and my healthcare peers about nutrition. *

People describe me as someone who can connect with diverse audiences. *

When facilitating groups, I can effectively draw people out or limit participation. *

I can organize my thinking, speaking, and materials to effectively deliver the presentation. *

I can monitor myself and adhere to a timed agenda throughout the course. *

Reference Letter

Please include a reference letter from a trusted colleague with whom you have worked in the past, or work with currently, who can speak to your interest in and ability to effectively deliver the requirements of this fellowship. *

Applicant Attestation and Signature

By submitting this application, the undersigned hereby acknowledges the information provided on this application is true and correct to the best of the applicant's knowledge, and the information may be provided and disclosed to the PA Foundation Nutrition Outreach Fellowship Review Committee and to any other person(s) authorized by the PA Foundation to review the information. The applicant authorizes the PA Foundation to verify any information provided in the application. Signature below hereby releases from liability any person(s) submitting information to the PA Foundation for use in the selection of fellowship recipients.

The applicant acknowledges that all Fellows are expected to meet the fellowship requirements as stipulated in the overview and requirements document. If such requirements are not met, the Foundation Board of Trustees will require full or partial reimbursement of stipend based upon unfulfilled required elements.

Applicant name in the section below will serve as an electronic signature and indicate applicant agrees with the above statement.

Please enter your electronic signature here. *

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Thank you for your responses!