2021 William H. Marquardt Community Health Access Fellowship
Application Form

Step 1: Review overview and requirements document.

Step 2: Fill out form below and upload all required supporting materials.

Application Deadline: September 10, 2021

General Information

Is this is self-nomination or are you nominating someone else? *

This is a self-nomination.

I am nominating someone else.

Name: *

AAPA ID: *

Employer: *

Job Title: *

Street Address: *

Address Line 2:

City: *

State: *

Zip Code: *

Email Address: *

Phone Number: *

Your Name: *

Your Email Address: *

Your Phone Number: *

Nominee Name: *

Nominee's AAPA ID: 🛈

Nominee Employer: *

Nominee Job Title: *

Nominee Street Address: *

Nominee Address Line 2:

Nominee City: *

Nominee State: *

Nominee Zip Code: *

Nominee Email Address: *

Nominee Phone Number: *

Community Health & Collaborative Service Activities

List your volunteer and/community activities over the past 3 years. (Limit 1,000 characters) *

0/1000 characters

List the nominee's volunteer and/community activities over the past 3 years. (Limit 1,000 characters) *

0/1000 characters

Describe your participation in community health initiatives, especially those that promote access to primary and preventive healthcare among underserved populations. (Limit 1,000 characters) *

0/1000 characters

Describe the nominee's participation in community health initiatives, especially those that promote access to primary and preventive healthcare among underserved populations. (Limit 1,000 characters) *

0/1000 characters

List your clinical rotation and/or employment experience in primary care. (Limit 1,000 characters) *

0/1000 characters

List the nominee's clinical rotation and/or employment experience in primary care. (Limit 1,000 characters) *

0/1000 characters

Provide examples of your experience collaborating with other healthcare providers in providing preventive healthcare to underserved populations. (Limit 1,000 characters) *

0/1000 characters

Provide examples of the nominee's experience collaborating with other healthcare providers in providing preventive healthcare to underserved populations. (Limit 1,000 characters) *

0/1000 characters

Essay/Letter of Recommendation

Write a brief essay describing your experiences and interest in community health initiatives and primary care medicine. (Maximum 5,000 characters) *

Provide a letter of recommendation that describes the nominee’s experiences and interest in community health initiatives and primary care medicine, and demonstrates how their experience/interest in those areas influences the next generation of providers. (Maximum 5,000 characters) *

Required Documents

Upload your current résumé/curriculum vitae (CV). *

Upload the nominee's current résumé/curriculum vitae (CV). *