Application for Admission Master of Health Sciences in Clinical Leadership Program Duke University School of Medicine

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1 Application for Admission Master of Health Sciences in Clinical Leadership Program Duke University School of Medicine Duke University is an Equal Opportunity institution. Duke University offers equal opportunity to all qualified applicants without regard to race, color, national or ethnic origin, handicap, sexual orientation or preference, sex, or age. The questions concerning race, sex, and national origin on the application form are for the purpose of meeting federal reporting requirements and are optional. Note: See Information for Applicants for complete application information. Mail this form to the Clinical Leadership Program, Department of Community and Family Medicine, Box , Duke University Medical Center, Durham, NC _ Last or Family Name First Middle Social Security Number - - Gender: Female Male 2. Country of citizenship If not US Citizen, indicate type of visa you hold 3. Date of Birth - - Place of Birth Month Day Year 4. Race/National origin White (not Hispanic) Asian or Pacific Islander (check one) Black (not Hispanic) Hispanic American Indian or Alaskan Native 5. address 6. Home Telephone Number ( ) and Home Mailing Address _ Number and Street City State Zip Code 7. DUMC Affiliation (if any) DUMC Box Department Division 8. Work Telephone Number ( ) and Mailing Address (if not DUMC) Number and Street City State Zip Code

2 *Official transcripts from all post-secondary/graduate institutions attended must be sent to the Clinical Leadership Program directly by the institution. Personal copies can not be accepted. 10. List in chronological order all post-secondary colleges and universities attended: From Through Major Degree or Institution Location Mo/Yr Mo/Yr Field Diploma 11. List in chronological order all residency, or fellowship training institutions attended: From Through Institution Location Mo/Yr Mo/Yr Field Do you have specialty boards or certifications? No Yes (please specify) 12. Beginning with your current or most recent position, list the last three positions that you have held for six months or longer: From Through Employer Location Mo/Yr Mo/Yr Position 13. Do you wish to be considered for admission as a degree candidate or as a non-degree participant? (Check one) Degree candidate Non-degree participant 14. Have you taken the General Aptitude Test (GRE) which is required of all applicants who do not have a graduate degree? Yes: Date - No: Date Scheduled - N/A Month Year Month Year

3 15. List three individuals who will supply letters of evaluation, preferably individuals not all from the same organization: (Use forms provided.) Name Position Institution 16. List any honors, distinctions, prizes or scholarships received: 17. If you have published papers, list up to three (journal, volume, page numbers and year) and enclose reprints: 18. Write a brief statement describing your clinical experience: _

4 19. Write a brief statement describing your administrative experience (program administration, strategic planning, supervision, budget preparation/management, etc.) 20. Write a brief statement describing your most challenging team experience. What did you learn from this experience? _ 21. Write a brief statement stating your career goals and the place of this program in accomplishing those goals: _ I hereby certify that the information given by me in this application and attached statements is complete and correct to the best of my knowledge. Signature Date

5 Information for Applicants PROGRAM OPTIONS Duke s Master of Health Sciences in Clinical Leadership Program (MHS-CL) offers clinicians an opportunity to expand their knowledge base and develop leadership skills. The MHS-CL s online, distance-based format is designed for professional clinicians. Classes are scheduled to accommodate the demands of clinical schedules. Classes make use of the students experience and students can use their workplaces as laboratories in which to practice their new skills. The program requires attendance at 3-4 day, on-campus sessions in Durham, NC at the beginning of each term.. On-campus dates are scheduled well in advance.. ADMISSION To be considered for admission, candidates must have all application materials submitted by the deadline for the semester for which they wish to begin the program. Materials received after the application deadline will automatically be considered for the following semester. Application deadlines are: May 1 To be considered for the fall semester September 1 To be considered for the spring semester February 1 To be considered for the summer semester Applicants seeking admission as a degree candidate or as a non-degree auditing student should submit the application form and provide the following supporting documents. Non-degree candidates are not required to complete an admission committee interview. Transcripts. An official transcript from each post-secondary institution attended must be sent to the Clinical Leadership Program directly by the institution. Personal copies are not acceptable. Letters of Evaluation. Three letters are required. One letter must come from someone who can testify to your clinical experience and one letter must come from someone who can testify to your administrative experience. All letters should be written by persons who are qualified to testify to your capacity for graduate work. Evaluation forms are provided; they should be mailed to the Clinical Leadership Program directly by the evaluators. Test Scores. Applicants who do not possess a graduate degree are required to provide scores on the Graduate Record Examination (GRE) General (Aptitude) Test. The scores must not be more than five years old and they must be mailed to the Clinical Leadership Program from the Educational Testing Service. Admissions Interview. Applicant finalists will be required to complete an admissions interview. APPLICATION FEE The non-refundable $100 application fee ($50 for non-degree candidates) must be included with the application for it to be considered complete. Checks should be made payable to Clinical Leadership Program.

6 TUITION Tuition for the degree program is approximately $39,600. Students are billed each semester. Once a student is admitted to the program, a non-refundable tuition deposit of $500 is required within ten days of admission to reserve a spot in the class. This amount is applied to the first tuition payment. Some students fund their own education, and others are sponsored entirely or in part by their employer. For those who are self-funded, Duke s School of Medicine Office of Financial Aid offers resources regarding loans and scholarships. We encourage you to contact them as soon as possible to begin that process. FOR MORE INFORMATION Visit our website: or contact Claudia J. Graham at or Claudia.Graham@duke.edu Division of Community Health Department of Community & Family Medicine DUMC Box Durham, NC