Form no number no number data collection questions

Attachment 3. Proposed Data Collection

TABLE OF CONTENTS

1. Introduction 2

2. LOGIN 3

2.1. Login 3

3. personal information 3

3.1. Name Information 3

3.2. Mailing Address 3

3.3. Information I wish to share with other alumni (choose one) (Alumni Directory only) 3

3.4. Contact Info 4

3.5. Citizenship Info 4

4. references 4

4.1. References 4

5. education 4

5.1. Education 4

5.2. Academic Honors 5

5.3. Clinical Training 5

5.4. Fellowship experience 5

5.5. Fellowship assignment 6

5.6. Additional Training 6

5.7. Licenses/board certification 6

5.8. Board certification 6

Work Experience 7

5.9. Work Experience 7

5.10. Internship or clerkship experiences 7

6. volunteer and community activities 7

6.1. Volunteer experience 7

6.2. Community activities 8

7. Research grants 8

7.1. Research grant(s) 8

8. presentations 8

8.1. Presentation(s) 8

9. publications 8

9.1. Publication(s) 8

10. honors and awards 9

10.1. Honors and awards 9

11. For student applicants 9

11.1. Logistics 9

12. knowledge and abilities 9

12.1. Knowledge and abilities 9

12.2. Languages 9

13. Additional Information 10

13.1. Area(s) of interest 10

13.2. Documentation of public health practice activities 10

14. essay 10

14.1. Essay 10

14.2. Family Information I wish to share with other alumni (Alumni Directory only) 10

1. Introduction

This document lists the universe of data elements that will be collected for the Fellowship Management System (FMS). Data elements include the fellowship application and updates to the alumni directory. Data elements are listed are in their respective logical group. However, not all data elements will be collected for all fellowships.

2. LOGIN

Listing of elements required to capture an individual’s login information.

1. Login

   1. Login (e-mail address)

   2. Password

   3. Secret question

   4. Secret question answer

3. personal information

Listing of elements required to capture an individual’s personal information.

1. Name Information

   1. Last name

   2. First name

   3. Middle name

   4. Has Your Last Name Changed?

   5. Current Last Name

   6. Any other name(s) that may appear on your academic records

2. Mailing Address

   1. Mailing Address

   2. Mailing City

   3. Mailing Country

   4. Mailing State

   5. Mailing Zip Code (Postal Code)

3. Information I wish to share with other alumni (choose one) (Alumni Directory only)

   1. Personal and professional information.

   2. None (Default)

4. Contact Info

   1. Daytime phone

   2. Evening phone

   3. Mobile number

   4. Personal e-mail

   5. Work e-mail

5. Citizenship Info

   1. Are you a US citizen? Yes/No

If no, then the following:

2. Are you a US permanent resident alien?

3. If you are neither a US citizen nor a lawful permanent resident, what type of visa do you have?

4. Country of citizenship

1. references

Listing of elements required to capture an individual’s references and related information.

1. References

   1. Name

   2. Title

   3. Organization

   4. Mailing address

   5. City

   6. State

   7. Zip Code (Postal Code)

   8. E-mail address

   9. Phone number

   10. Relationship to you

5. education

Listing of elements required to capture an individual’s education and related information.

1. Education

   1. Name of institution

   2. Institution Address

   3. Institution City

   4. Institution State

   5. Institution Zip Code (Postal Code)

   6. Institution Country

   7. From date

   8. To date

   9. Status

   10. Degree Received

   11. Date awarded or expected

   12. Major

   13. Minor

   14. Specialty

   15. GPA

   16. Please state reason for change of undergraduate institution if applicable

   17. Thesis or dissertation Title

   18. Date of completion (of thesis/dissertation)

   19. Current year of medical or veterinary school if applicable (applicants to student programs only).

   20. Classes or training in public health-relevant fields

2. Academic Honors

   1. Institution/organization name

   2. Date awarded

   3. Type

   4. Additional information

3. Clinical Training

   1. Hospital or institution

   2. Country

   3. City

   4. State

   5. Title

   6. Specialty type

   7. Year started

   8. Year ended

4. Fellowship experience

   1. Fellowship

   2. Organization

   3. From date

   4. To date

5. Fellowship assignment

   1. Assignment Name

   2. Primary Focus Area

   3. City

   4. State

   5. From date

   6. To date

6. Additional Training

   1. Institution/organization name

   2. Institution Address

   3. Institution City

   4. Institution State

   5. Institution Zip Code (Postal Code)

   6. Institution Country

   7. From date

   8. To date

   9. Certificate

   10. Date awarded or expected

   11. Brief description of training

7. Licenses/board certification

   1. Issuing state

   2. License number

   3. Expiration date

   4. If foreign medical graduate, Education Commission for Foreign Medical Graduates (ECFMG) status .

8. Board certification

   1. Specialty

   2. Year awarded

   3. Expiration date

Work Experience

Listing of elements required to capture an individual’s work experience and related information.

9. Work Experience

   1. Employer Name

   2. Employer Country

   3. Employer Address

   4. Employer City

   5. Employer State

   6. Employer Zip Code (Postal Code)

   7. From date

   8. To date

   9. Work Setting

   10. Job title

   11. Job Function

   12. Job Role

   13. Reason for leaving

   14. Supervisor’s name

   15. May the supervisor be contacted?

   16. Supervisor’s address

   17. Supervisor’s phone number

   18. Average hours per week

10. Internship or clerkship experiences

    1. Organization or agency

    2. City

    3. State

    4. Country

    5. From date

    6. To date

    7. Job title

    8. Duties, accomplishments, responsibilities

    9. Average hours per week

6. volunteer and community activities

Listing of elements required to capture an individual’s volunteer and community activities.

1. Volunteer experience

   1. Organization name

   2. Address

   3. From date

   4. To date

   5. Job title

   6. Duties and accomplishments

   7. Reason for leaving

   8. Supervisor’s name

   9. May the supervisor be contacted?

   10. Supervisor’s address

   11. Supervisor’s phone number

   12. Average hours per week

2. Community activities

   1. Name of organization

   2. Role

   3. Dates of participation

7. Research grants

Listing of elements required to capture an individual’s research grant information.

1. Research grant(s)

   1. Date

   2. Title

   3. Funding agency

   4. Description of activities

8. presentations

Listing of elements required to capture an individual’s presentation experience.

1. Presentation(s)

   1. Citation

9. publications

Listing of elements required to capture an individual’s publication information.

1. Publication(s)

   1. Citation

10. honors and awards

Listing of elements required to capture an individual’s honors and awards.

1. Honors and awards

   1. Name of award

   2. Type of honor

   3. Name of organization

   4. Date received

11. For student applicants

Listing of elements required to capture student applicant information.

1. Logistics

   1. Funding requested (yes/no)

   2. Time Period requested for rotation

12. knowledge and abilities

Listing of elements required to capture an individual’s knowledge and abilities.

1. Knowledge and abilities

   1. Specialized Software Packages

   2. Information Systems and Technology

   3. Computer Science

   4. Information Science

   5. Management

   6. Public Health and Healthcare

   7. Research

   8. Communication

2. Languages

   1. Read (aptitude)

   2. Write (aptitude)

   3. Speak (aptitude)

13. Additional Information

Listing of elements

1. Area(s) of interest

2. Documentation of public health practice activities

14. essay

Listing of elements required to capture an individual’s essay during the application process.

1. Essay

   1. Applicant Essay

16 ADDITONAL PERSONAL INFORMATION FOR ALUMNI DIRECTORY

2. Family Information I wish to share with other alumni (Alumni Directory only)

   1. Spouse/Partner Name (optional)

   2. Spouse/Partner was/is also a fellow (optional)

   3. Spouse/Partner fellowship year (optional)

   4. Child Name (optional)