Interdisciplinary GeroPsych/Behavioral Disorders Traineeship

Interdisciplinary GeroPsych/Behavioral Disorders Traineeship

Application Form

To submit the Traineeship Application electronically please fill out the form below and click the submit button. The information you fill out will be sent to your email address. You will then need to forward this email to info@ascpfoundation.org and attach your additional required documents (Exhibits) to it.

Pharmacist:
Name:
Degree(s):
Employer/Company Name:
Preferred Mailing Address:
City:
State:
Zip Code:
Telephone:
Fax:
E-mail:

CHECK ONE:	Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist
Name:
Degree:
Employer/Company Name:
Preferred Mailing Address:
City:
State:
Zip Code:
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. For applicants who are self-employed, the letter should be from the applicant, addressed to the ASCP Foundation, and should state that the applicant is self-employed and able to participate and implement the results of the traineeship experience.

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.

(Please
type Yes
if you agree.)

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.

Applicant 1 Signature:
(Type if submitting electronically)
Date:

Applicant 2 Signature:
(Type if submitting electronically)
Date:

Deadline for Receipt of Applications: August 3, 2007