Interdisciplinary GeroPsych/Behavioral Disorders Traineeship

Policies & Guidelines Application Form Curriculum General Information

Application Form

To submit the Traineeship Application electronically, click here to complete the online form and follow the instructions as specified. You may also submit the form by postal mail by following the directions located at the bottom of this form.

Pharmacist:

Name
Degrees(s)
Employer/Company Name
Preferred Mailing Address
City, State, Zip
Telephone	Fax	E-mail

CHECK ONE:

Physician		Nurse Practitioner
Physician Assistant		Clinical Nurse Specialist

 

Name
Degrees(s)
Employer/Company Name
Preferred Mailing Address
City, State, Zip
Telephone	Fax	E-mail

TRAINEESHIP DATE: The traineeship will take place October 22-26.

ADDITIONAL APPLICATION DOCUMENTS REQUIRED: The following items are to be appended to this form, each clearly labeled in the upper right-hand corner, as indicated (Exhibit A, Exhibit B, Exhibit C, Exhibit D):

Exhibit A. Curriculum vitae from each team member, which must include the applicant’s education, experience record in pharmacy practice/medicine/nursing (in reverse chronological order, most recent first), and any relevant publications, presentations, and community service.

Exhibit B. Statement of not more than four typed, double-spaced pages describing: (1) why the applicant team wants to participate in the traineeship and the applicant team’s expectations of the traineeship experience; (2) nature and extent of professional or personal involvement with persons with psychiatric or behavioral disorders; (3) current level of clinical services provided by the applicant team members, including total number of patients served, geographic distribution (urban, rural, suburban), ethnic distribution (Black, White, Hispanic, Asian/Pacific Islander, American Indian/Eskimo/Aleut), and number of patients with psychiatric or behavioral disorders; (4) special services or programs provided by the applicant team members; (5) how the traineeship will enhance the interdisciplinary clinical services provided by the applicant team; and (6) how the results of the traineeship experience will be incorporated into the applicant team’s collaborative practice.

Exhibit C*. Letter(s) from the applicant team members’ employer(s) confirming support for their participation in the traineeship and willingness to implement the results of the traineeship experience. Letters should be addressed to the applicant(s) and signed by the chief executive officer, administrator, medical director, director of pharmacy, clinical coordinator, or other appropriate manager/supervisor in the organization.

Exhibit D. A joint statement from the applicant team explaining: (1) any current or past experience working together, including the type of collaboration, monthly hours of collaboration, and years of collaboration; and (2) plans for collaboration after completing the traineeship (i.e., how the team will work together), including the type of collaboration, business model, anticipated monthly hours of collaboration, anticipated locations served, and anticipated number of patients seen per month by either team member.

*If the applicants are self-employed, this exhibit may be omitted.

We certify that the information we have submitted in this application and the accompanying exhibits are complete and correct to the best of our knowledge and belief.

If submitting by mail, send the completed application form with the exhibits attached to: ASCP Foundation, 1321 Duke Street, Alexandria, VA 22314.

Deadline for Receipt of Applications: August 3, 2007