HIV Mini-Residency Program -Albany Application

APPLICATION FORM

 
Due to our grant catchment, you must be a citizen of the United States and be a licensed and practicing health care provider in the state of New York to apply.

This training opportunity is open to community and correctional health care providers. Applicants may have basic or advanced HIV experience, as individualized programs are designed to meet providers knowledge and comfort levels related to treating HIV/AIDS.
Please specify your discipline (limited to these professions):
Demographic Information
Fax:
Date of Birth (for security clearance only):
MM DD YYYY
DOB
/
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Please specify what you would like your training to consist of:
How many days are you available to train?
Giving 6-8 weeks notice, please give your date preference for a training period.
The ACCESS Certificate Program is a unique integration of didactic and experiential training, providing participants with access to the diverse conferences, workshops, preceptorships and consultation services offered by the NY/NJ AETC. It is a multiple-day individualized training for minority and minority serving providers working in communities highly impacted by HIV.



Would you like information about the ACCESS Certificate Program?
If you are interested in a didactic training component, from the list of topics below, choose your 5 preferences in the boxes provided:
Please fax or mail the following documents to the below contact information:

-Copy of your license
-Copy of your curriculum vitae
-A brief paragraph stating your training goals
-Letter from a health care provider (within the last year) which documents:
-Your name
-Immunity to Rubella
-A recent PPD indicating either a negative or positive result. If positive, documentation you have received treatment and are not considered contagious

Please mail documents to:
Cathryn Corlew, Mini-Residency Coordinator
47 New Scotland Ave
Mail Code 158
Albany, NY 12208

Questions?
Phone: 518-262-6864
Fax: 518-262-8460
E-mail: corlewc@mail.amc.edu