Scholars Application 2019-2020

Oklahoma AHEC Scholars Program Application

The Area Health Education Center (AHEC) Scholars Program is a two-year program with interprofessional curricula that includes 80 contact hours per program year comprised of clinical, didactic, and community based interprofessional education. Clinical and community-based training will occur in Oklahoma rural and/or underserved settings in collaboration with OK AHEC’s three regional centers and the Oklahoma State University Center for Health Sciences. Eligible students include any students enrolled in a health professions training program. Examples include medical, nurse practitioner, pharmacy, and public health students.

All students who complete the program will receive a certificate of completion. AHEC is a nationwide Health Resources Services Administration (HRSA) program that will identify AHEC Scholars students as having specialized training and experience with rural, and underserved communities.

Once received and reviewed you will be notified regarding the status of your application and whether you have been accepted to the program. Thank you for applying!

Please contact the AHEC Center Director in the region in which you are applying for more information about the benefits of becoming and AHEC Scholar.

Lawton, Oklahoma: Danielle Dewey danielle.dewey@ccmhhealth.com

Enid, Oklahoma: Becky Zook- bkzook@nwosu.edu

Tahlequah, Oklahoma: Michele Horn- mhorn@nhs-ok.org

Program Eligibility

Must be enrolled in a college-level health professions education training program in Oklahoma by December 31st, 2018 and maintain a 2.5 GPA (transcript required)
Have reliable access to Wi-Fi
Have reliable transportation
Be eligible to work in the United States

Requirements

Be committed to the program for a total of two years
Complete 40 hours of didactic training each program year
Complete 40 hours of clinical training each program year
Sign up for a free Connect US Health account

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* 1. To which AHEC Center are you applying?

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* 2. Contact Information

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

County *

Email Address *

Phone Number *

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* 3. Alternative personal email address for post program contact.

Email Address

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* 4. Race/Ethnicity for federal reporting requirements (Please select all that apply)

American Indian/Alaskan Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Native Hawaiian/Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Marshall Islands or other Pacific Islands.

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Black or African American: A person having origins in any of the black racial groups of Africa.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Other (please specify)

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* 5. Birthdate

Date / Time

Date

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* 6. Please check the gender with which you identify?

Female

Male

Other

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* 7. Veteran Status

Active Duty

Reservist

Veteran Prior Service

Veteran Retired

Not a Veteran

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* 8. Do you speak any languages other than English?

Yes

If yes, what other languages do you speak?

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* 9. What community did you grow up in or consider your childhood home?

City/Town

State/Province

ZIP/Postal Code

County

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* 10. Do you consider yourself from a rural background?

Yes

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* 11. High School Education

Name of High School

Graduation Year

City

State

County

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* 12. College Education

College/University/Community College you are currently attending

Anticipated Graduation Date

City

State

County

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* 13. Discipline/Program Enrolled

Allied Health (laboratory technologists, occupational therapy, audiologists, etc)

Dental

Dietitian

Medicine (DO/MD)

Nursing (specify specialty)

Optometry

Pharmacy

Physical Therapy

Physicians Assistant

Psychologist/Counselor

Public Health

Radiography

Respiratory

Social Work

Other/specialty (please specify)

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* 14. What academic honors and/or scholarships have you received?

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* 15. What extracurricular activities have you participated, including any volunteer activities in rural or underserved areas?

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* 16. Would you consider yourself from an "environmentally disadvantaged background"? Please answer to the best of your ability.

This means an individual who:

(1) Comes from an environment that inhibited the individual from obtaining the knowledge, skill, and ability required to enroll in and graduate from a health professions school; or

(2) Comes from a family with an annual income below a level based on low-income thresholds according to family size published by the U.S. Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary for use in all health professions programs.

Yes

Not sure

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* 17. Do you fall into any of the following categories? Choose all that apply.

You are from a high school with low average SAT/ACT scores.

You are from a school district where 50% or less of graduates go on to college.

You have a diagnosed physical/mental impairment substantially limiting participation in education.

English is not your primary language and has been a barrier to academic performance.

You are the first generation in your family to attend college.

You are from a high school where greater than 30% of students were eligible for free or reduced lunch prices.

You come from a family with an annual income less than 200% of the Federal Poverty Level (Currently $32,920 for a family of 2; $41,560 for a family of 3; $50,200 for a family of 4; $58,840 for a family of 5)

You come from a family that received public assistance (e.g., Temporary Assistance to Needy Families (TANF), Aid to Families with Dependent Children, Supplemental Assistance to Needy Families (SNAP/Food Stamps), WIC, Medicaid, public housing).

You qualified for a need-based scholarship.

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* 18. Does your father, mother, spouse, or immediate family work in healthcare?

Yes

If you answered yes to the above, who?

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* 19. How did you learn about the OK AHEC Scholars Program?

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* 20. Have you participated in AHEC health careers program?

Yes

If yes, state which AHEC, the program name, and the dates attended:

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* 21. Please indicate any health career programs at Oklahoma State University Center for Health Sciences in which you have participated.

Operation Orange

Med-Xtravaganza

MAPS Conference

Undergraduate Days

Dr. Pete's Student for a Day

Dr. Petes Medical Immersion Camp

Native OKStars Program

Other (please specify)

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* 22. Please indicate the setting in which you plan to WORK after the completion of your medical education.

Large city (population 500,000 or more)

Suburb of a large city

City of a moderate size (population 50,000 to 499,999)

Suburb of moderate size city

Small city (population 10,000 to 49,999 -- other than suburb)

Town (population 2,500 to 9,999 -- other than suburb)

Small town (population less than 2,500)

Undecided/No preference

Other (please specify)

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* 23. In 100-250 words, please write a brief explanation about why you are interested in being an Oklahoma AHEC Scholar.

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* 24. I understand the requirements and timeline of the Oklahoma AHEC Scholars Program.

Yes

Need more information

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* 25. I consent to be contacted by the Oklahoma AHEC Scholars program one year following graduation about my practice type and work location. *This is a requirement of program participation.

Yes

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* 26. I understand and acknowledge that the AHEC Scholars Director and staff will review the personal data I provide on this form. The information I provide on this form will be maintained securely to ensure my privacy and will only be shared with the Oklahoma AHEC Program Office and the relevant Oklahoma AHEC Center faculty and staff. Typing your name below constitutes as a signature.