Thank you for your interest in HEAL-UTSW. Please complete the application in full.

The submission deadline is May 13, 2024.

If you have any questions or comments, please email: HEAL@utsouthwestern.edu.

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* 1. First Name

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* 2. Last Name

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* 3. Full name of your institution.  NO ABBREVIATIONS

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* 4. I am a

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* 5. Select your rank

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* 6. Select your program year

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* 7. What is the name of your department/office

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* 8. What is your role at your institution

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* 9. What is your specialty

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* 10. Please provide your work email

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* 11. Please provide your personal email

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* 12. What is your preferred email for use

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* 13. What is your personal phone number for contact if necessary

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* 14. Please provide your Program Director's first and last name

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* 15. Please provide your Program Director's email

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* 16. Please provide your Department Chair's first and last name

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* 17. Please provide your Department Chair's email 

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* 18. If you are not a trainee or faculty member, what role or capacity within the program are you interested in?

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* 19. If accepted to the HEAL-UTSW program. I agree to attend and actively participate in the monthly virtual sessions.  Select "yes" if you agree.

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* 20. Why do you want to join HEAL-UTSW

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* 21. What do you hope to gain from HEAL-UTSW

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