2023 to 2024 HIVMA and IDSA Foundation Clinical Fellowship Application

Please complete this form that requests general information and a personal statement (500 words or less) regarding your experience, interests and professional goals. To complete your application:

Email your CV, training curricula and two professional references to info@hivma.org.
See Recommended Competencies for HIVMA Clinical Fellows for guidance.
Ensure your mentor has completed the sponsor registration form.

The deadline for all application materials is Monday, December 12, 2022. Please email HIVMA with any questions.

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* 1. General Information

First Name

Middle Initials

Last Name

Degree(s)

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* 2. General Information (Optional)

Preferred Pronouns

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* 3. Contact Information

Street Address

Address Line 2

City

State

Zip

Phone

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* 4. Email

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* 5. Training Status/Practice Experience

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* 6. Race/Ethnicity (optional):

Inclusion, diversity, access and equity: special consideration will be given to Black/African American and Hispanic/Latino candidates because of the disproportionate impact of the HIV epidemic on these populations, and because they are under-represented in the HIV medical workforce.

American Indian/Native Alaskan

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White/Caucasian

Other (please specify)

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* 7. Gender (optional):

Female

Male

Transgender Female/Trans Woman

Transgender Male/Trans Man

Non-Binary/Genderq

Other

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* 8. Are you legally authorized to work in the U.S.?

Yes

Yes, but my work visa expires on

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* 9. Are you currently pursuing or receiving fellowship funding from other sources?

Yes

If ‘Yes’, please list other sources:

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* 10. Are you applying for a full-time or half-time award?

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* 11. PERSONAL STATEMENT: In 500 words or less, please discuss your career and professional goals and objectives as they relate to the care of people with HIV and your prior training and how it relates to an interest in expanding education and training in HIV medicine. In developing your statement, please be as specific as possible and focus on your professional experience and goals. Please also share how you have worked to address health equity in your work or practice if applicable.

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* 12. Please indicate the patient populations that you are interested in working with:

Adults

Adolescents

Children

Men who have sex with Men

Women

Transgender

Other (please specify)

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* 13. Have you contacted a sponsor?

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* 14. Sponsorship Information (*If you selected 'No', you must contact us before submitting your application to be matched with a sponsor in your desired area.)

Sponsor's Name

Sponsor's Phone

Sponsor's E-mail

Sponsoring Institution

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* 15. Is your sponsoring institution aware that you are applying for this fellowship? (Important - You must contact your institution’s administrators immediately to make them aware that you will be applying for this fellowship. For more information about this, please contact us.)

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* 16. How did you learn about the HIVMA Clinical Fellowship Program?

Google or other search engine

HIVMA member

Training Program Director

Other (please specify)