FMS Application Module (2020-revised June 2021)

Fellowship Management System

Attachment 3_FMS 2.0 Application Module-June 2021

Fellowship Applications

OMB: 0920-0765

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0765 can be found here:

2024-01-04 - No material or nonsubstantive change to a currently approved collection
2023-11-08 - No material or nonsubstantive change to a currently approved collection

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Fellowship Management System (FMS)
FMS Application Module

2020
Privacy Act and Public Burden Information
Privacy Act Information
The Privacy Act applies to this information collection. Information collected will be kept private as noted in the System of Records Notice is 09-20-0112,
Fellowship Program and Guest Researcher Records.
Public Burden Information
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Public reporting burden of this collection of information is an estimated average of 66 minutes per response, with an additional 15 minutes for the reference
letter writers (total 81 min), and including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333;
ATTN: PRA (0920-0765).

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table of Contents
Table of Contents ........................................................................................................................................................................................................... 2
1.

Introduction ........................................................................................................................................................................................................... 7
1.1

Document Structure....................................................................................................................................................................................... 8

Sign-In & Sign-Up Pages ......................................................................................................................................................................................... 9
2.1

Sign-In Page .................................................................................................................................................................................................... 9

2.2

Sign-Up Page (For New Users) ..................................................................................................................................................................... 11

eFMS System Help Desk Ticket ............................................................................................................................................................................ 12

Application Welcome Page .................................................................................................................................................................................. 14

Applicant Profile................................................................................................................................................................................................... 15

5.1

Create a Profile to Get Started..................................................................................................................................................................... 15

5.2

Applicant Name............................................................................................................................................................................................ 16

5.3

Email Address ............................................................................................................................................................................................... 17

5.4

Phone Number ............................................................................................................................................................................................. 18

5.5

Mailing Address............................................................................................................................................................................................ 19

5.6

Emergency Contact ...................................................................................................................................................................................... 20

Eligibility ............................................................................................................................................................................................................... 21
6.1

Get Started ................................................................................................................................................................................................... 21

6.2

Citizenship Status ......................................................................................................................................................................................... 23

6.3

TOEFL Score.................................................................................................................................................................................................. 25

6.4

PMR/F .......................................................................................................................................................................................................... 26

6.4.1

Attachment 3 – FMS Application Module

6.4.2

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Commissioned Corps............................................................................................................................................................................ 30

6.4.3 Public Health Work Experience ................................................................................................................................................................... 31
6.5

PHIFP ............................................................................................................................................................................................................ 32

6.5.1
6.6

SAF................................................................................................................................................................................................................ 34

6.6.1
6.7

Academic Endorsement ....................................................................................................................................................................... 35

PHAP............................................................................................................................................................................................................. 36

6.8.1
6.9

Teaching Experience ............................................................................................................................................................................ 34

EEP................................................................................................................................................................................................................ 35

6.7.1
6.8

Special Requirements........................................................................................................................................................................... 36

FLIGHT .......................................................................................................................................................................................................... 41

6.9.1

Clinical Category & Training ................................................................................................................................................................. 41

6.9.2

Current EIS Position ............................................................................................................................................................................. 42

6.9.3

Current Primary Supervisor.................................................................................................................................................................. 43

6.9.4

Scientific Experience ............................................................................................................................................................................ 44

6.10

PH-TIPP......................................................................................................................................................................................................... 46

6.10.1

6.10.2

Program & Organization ...................................................................................................................................................................... 47

6.10.3

Host Site Position Description .............................................................................................................................................................. 49

6.11

ELI ................................................................................................................................................................................................................. 52

6.11.1

Organization Details ............................................................................................................................................................................. 52

6.11.2

Educational Experience ........................................................................................................................................................................ 54

6.11.3

Work Experience .................................................................................................................................................................................. 56

Attachment 3 – FMS Application Module

6.11.4

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

e-Learning Content Example ................................................................................................................................................................ 58

6.12 EIS..................................................................................................................................................................................................................... 60
6.12.1 EIS Federal Student Loan Repayment Interest ......................................................................................................................................... 60
6.12
7.

Confirming Accuracy & Minimum Eligibility ................................................................................................................................................ 63

Education & Licenses ........................................................................................................................................................................................... 64
7.1

Adding Education or Licenses ...................................................................................................................................................................... 64

7.2

Choose Category .......................................................................................................................................................................................... 66

7.3

Coursework Type ......................................................................................................................................................................................... 67

7.4

Location........................................................................................................................................................................................................ 68

7.5

College/University ........................................................................................................................................................................................ 69

7.6

Status ........................................................................................................................................................................................................... 70

7.7

Degree .......................................................................................................................................................................................................... 71

7.8

Additional Coursework ................................................................................................................................................................................ 73

7.9

License.......................................................................................................................................................................................................... 74

7.10

Dates ............................................................................................................................................................................................................ 75

7.11

Incomplete Reason ...................................................................................................................................................................................... 77

Work & Volunteer Experience ............................................................................................................................................................................. 78
8.1

Adding Work or Volunteer Experience ........................................................................................................................................................ 78

8.2

8.3

Organization Details ..................................................................................................................................................................................... 80

8.4

Position Details ............................................................................................................................................................................................ 82

8.5

8.6

Position Location .......................................................................................................................................................................................... 85

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Additional Training & Skills .................................................................................................................................................................................. 87
9.1

Adding Additional Training & Skills .............................................................................................................................................................. 87

9.2

9.3

Clinical Training ............................................................................................................................................................................................ 89

9.4

U.S. Board Certifications and Specialty ........................................................................................................................................................ 90

9.5

Additional Training, Certifications, or Professional Development .............................................................................................................. 91

9.6

Institution Details and Location ................................................................................................................................................................... 92

9.7

9.8

Language Skills ............................................................................................................................................................................................. 95

10.

Publications, Presentations, Working Papers, Monographs or Reports, Grants, Honors and Awards ........................................................... 97

10.1

Adding Publications, Presentations, Working Papers, Monographs or Reports, Grants, Honors and Awards ........................................... 97

10.2

10.3

Details ........................................................................................................................................................................................................ 100

11.

Personal Statement........................................................................................................................................................................................ 102

11.1

All Fellowships except FLIGHT.................................................................................................................................................................... 102

11.2

11.3 Location Preferences ..................................................................................................................................................................................... 108
11.4 CDC Fellowship Participation ......................................................................................................................................................................... 110
12.

Standardized Letters of Recommendation (SLOR)......................................................................................................................................... 115

12.1

SLOR Requests ........................................................................................................................................................................................... 115

12.1.1

Starting a SLOR Request ..................................................................................................................................................................... 115

12.1.2

SLOR Request Fields ........................................................................................................................................................................... 116

12.2

System Emails to Letter Writers................................................................................................................................................................. 120

Attachment 3 – FMS Application Module

12.3

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Letters of Recommendation ...................................................................................................................................................................... 121

12.3.1

Section A ............................................................................................................................................................................................ 121

12.3.2

Section B............................................................................................................................................................................................. 123

12.3.3

Section C............................................................................................................................................................................................. 131

13.

Final Application Sections .............................................................................................................................................................................. 133

13.1 Self-Assessment of Skills ................................................................................................................................................................................ 133
13.1.1 PHIFP ....................................................................................................................................................................................................... 133
13.1.2 PE ............................................................................................................................................................................................................ 137
13.2

Applicant Survey ........................................................................................................................................................................................ 142

13.3

EEP Rotation Preferences & Topic/Subject Areas...................................................................................................................................... 147

13.3.1

Rotation Preferences ......................................................................................................................................................................... 147

13.3.2 Topic & Subject Areas ............................................................................................................................................................................. 149
13.3.3 Location Preferences .............................................................................................................................................................................. 152
13.4 SAF Public Health Interests ............................................................................................................................................................................ 154
13.5 EIS CIO Assignment Interests ......................................................................................................................................................................... 156
13.6. Writing Samples ............................................................................................................................................................................................ 160
13.6.1 EIS Writing Samples ................................................................................................................................................................................ 160
14.

Match ............................................................................................................................................................................................................. 161

14.1

Match or Prematch Rank/Rating Form ...................................................................................................................................................... 161

14.2

Match or Prematch Acceptance Form ....................................................................................................................................................... 163

Appendix .................................................................................................................................................................................................................... 167
I. Field Value Tables............................................................................................................................................................................................... 167
II. Lookup Tables.................................................................................................................................................................................................... 171

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

1. Introduction
The purpose of this document is to list all the data elements collected online through the Fellowship Management System (FMS). The FMS
online application module is a streamlined mechanism for applicants of the Centers for Disease Control and Prevention (CDC) fellowships to
submit their information online and track statuses of the application processes (e.g., all required materials received, invited for interviews).
The FMS is a robust flexible framework and the FMS Application Module is tailored successfully for various CDC fellowships:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Epidemic Intelligence Service (EIS)
CDC E-learning Institute (ELI)
Epidemiology Elective Program (EEP)
Future Leaders in Infections and Global Health Threats (FLIGHT)
Laboratory Leadership Service (LLS)
CDC Steven M. Teutsch Prevention Effectiveness (PE) Fellowship
Public Health Associate Program (PHAP)
Public Health Informatics Fellowship Program (PHIFP)
Science Ambassador Fellowship (SAF)
Preventive Medicine Residency and Fellowship (PMR/F)
Population Health Training in Place Program (PH-TIPP)

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

1.1 Document Structure
This document is broken down by the major pages of the FMS Application. In this document, each page of the FMS Application has sections
and some sub-sections. In addition, application instructions, login, and registration pages are included. Instructions and emails in the FMS
Application are tailored to each CDC fellowship’s requirements, eligibility criteria, information, and timeline.
Following the screenshots in each section is a table that shows the status of the collection of data elements by each CDC fellowships. The
following labels indicate the status of the collection:
•
•
•

“Yes” indicates that the fellowship collects the information and that applicants are required to submit this information.
“No” indicates that the fellowship does not collect this information.
“-” indicates open text field

In addition, the table shows the data values of each data element, and for ones that have a list of dropdown values, the data value category
is hyperlinked to its list located in the Appendix.

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

2. Sign-In & Sign-Up Pages
2.1 Sign-In Page
Figure 2.1-a. Sign-In Page

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Figure 2.1-b. Privacy Act and Public Burden Information

Table 2.1-a. Sign-In Fields
Field
Email

Values
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Password

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

2.2 Sign-Up Page (For New Users)
Figure 2.2-a. Sign-Up Fields

Table 2.2-a. Sign-Up Fields
Field

Values
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Password

Yes

Confirm Password

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

3. eFMS System Help Desk Ticket
Figure 3-a. eFMS System Help Desk Ticket Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 3-a. eFMS System Help Desk Ticket Fields
Field

Values
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Sign-In Email:

Yes

Contact Phone Number:

Yes

Your Name:

Fellowship:

Fellowship Lookup Table

Yes

What type of issue or need do you have?

1. System Error Message
2. Sign-In or Password
3. Smart Card Sign-In
4. Data Not Saving
5. Unable to Submit
6. Reset application back to "Draft"
7. Withdraw Fellowship Application
8. Other

Yes

URL where the issue is occurring:

Yes

Error code message:

Yes

Please describe your issue or need:

Yes

Screenshot of error or issue (optional):

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

4. Application Welcome Page
Figure 4-a. Application Welcome Page

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

5. Applicant Profile
5.1 Create a Profile to Get Started
Figure 5.1-a. Create a Profile to Get Started

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

5.2 Applicant Name
Figure 5.2-a. Applicant Name Fields

Table 5.2-a. Applicant Name Fields
Field
First Name:
Middle Name:
Last Name:
Suffix:
Other Name:
Preferred Name:

Values
-

EIS
Yes
Yes
Yes
Yes
Yes
Yes

LLS
Yes
Yes
Yes
Yes
Yes
Yes

FLIGHT
Yes
Yes
Yes
Yes
Yes
Yes

EEP
Yes
Yes
Yes
Yes
Yes
Yes

SAF
Yes
Yes
Yes
Yes
Yes
Yes

PMR/F
Yes
Yes
Yes
Yes
Yes
Yes

PH-TIPP
Yes
Yes
Yes
Yes
Yes
Yes

PHIFP
Yes
Yes
Yes
Yes
Yes
Yes

PE
Yes
Yes
Yes
Yes
Yes
Yes

ELI
Yes
Yes
Yes
Yes
Yes
Yes

PHAP
Yes
Yes
Yes
Yes
Yes
Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

5.3 Email Address
Figure 5.3-a. Email Address Fields

Table 5.3-a. Email Address Fields
Field
Primary Email Address:

By checking this box, you confirm that the
email address above is accurate:
Secondary/Alternate Email Address:

Values
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

1. I confirm that the email address
above is accurate.

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

5.4 Phone Number
Figure 5.4-a. Phone Number Fields

Table 5.4-a. Phone Number Fields
Field
Phone Code:
Primary Phone Number:

By checking this box, you confirm that the phone
number above is accurate:
Secondary/Alternate Phone Number:

Values
Phone Code Lookup Table
-

1. I confirm that the phone
number above is accurate.
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

5.5 Mailing Address
Figure 5.5-a. Mailing Address Fields

Table 5.5-a. Mailing Address Fields
Field
Mailing Address:
Mailing Address Line 2:

Values
-

EIS
Yes
Yes

LLS
Yes
Yes

FLIGHT
Yes
Yes

EEP
Yes
Yes

SAF
Yes
Yes

PMR/F
Yes
Yes

PH-TIPP
Yes
Yes

PHIFP
Yes
Yes

PE
Yes
Yes

ELI
Yes
Yes

PHAP
Yes
Yes

Mailing Address Line 3:

Yes

Yes
Yes

Country:
State/Territory:

Country Lookup Table
State/Territory Lookup Table

State/Province:

Yes

City:
Zip/Postal Code:

Yes
Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

5.6 Emergency Contact
Figure 5.6-a. Emergency Contact Fields

Table 5.6-a. Emergency Contact Fields
Field
EC Full Name:
EC Relationship:
EC Phone Number:
EC Email:

Values
-

EIS
Yes
Yes
Yes
Yes

LLS
Yes
Yes
Yes
Yes

FLIGHT
Yes
Yes
Yes
Yes

EEP
Yes
Yes
Yes
Yes

SAF
Yes
Yes
Yes
Yes

PMR/F
Yes
Yes
Yes
Yes

PH-TIPP
Yes
Yes
Yes
Yes

PHIFP
Yes
Yes
Yes
Yes

PE
Yes
Yes
Yes
Yes

ELI
Yes
Yes
Yes
Yes

PHAP
Yes
Yes
Yes
Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6. Eligibility
6.1 Get Started
Figure 6.1-a. Get Started

Table 6.1-a. Get Started
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Application and documents must be
submitted by 05:00pm (ET)

Yes

Complete all sections of the online
application

Yes

-Each section must have at least 1
entry to successfully submit

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

-All supporting materials, including
letters of recommendation, must
be received by the deadline
-Please review the fellowship
website for further instructions
about supporting materials
-Re-applicants must click the "add
another" button to create a new
application. Re-submitting your old
application will not count as a
submission for this year.

Figure 6.1-a. Part 1: Eligibility Stage

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

6.2 Citizenship Status
Figure 6.2-a. Citizenship Status Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.2-a. Citizenship Status Fields
Field
Country of Birth:
Country of Citizenship:
Are you a U.S. permanent resident?

Values
Country Lookup
Country Lookup
1. Yes
2. No

EIS
No
Yes
Yes

LLS
No
Yes
Yes

FLIGHT
No
No
No

EEP
No
Yes
No

SAF
No
Yes
No

PMR/F
Yes
Yes
Yes

PH-TIPP
Yes
Yes
Yes

PHIFP
No
Yes
Yes

PE
No
Yes
Yes

ELI
No
Yes
Yes

PHAP
Yes
Yes
Yes

Do you currently live in the U.S.?

1. Yes
2. No

Yes

Visa Type:

1. F-1
2. H-1B
3. J-1
4. O-1
5. TN
6. Other

Yes

Specify Visa Type:
Visa Expiration Date:
Do you have a completed degree
from the approved TOEFL exempt
countries list?
Which degree is your country from?

1. Yes
2. No
Approved
Country List

Yes

Yes
Yes
Yes

No
No
No

Yes
Yes
No

No
No
No

Yes
Yes
No

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.3 TOEFL Score
Figure 6.3-a. TOEFL Score Fields

Table 6.3-a. TOEFL Score Fields
Field
TOEFL Test Type:

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

1. Internet-Based Test
2. Computer-Based Test
3. Paper-Based Test

Yes

TOEFL Score:

Yes

TOEFL Score Upload:

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.4 PMR/F
6.4.1 Eligibility

Figure 6.4.1-a. Eligibility Fields

Figure 6.4.1-b. Eligibility Fields

Figure 6.4.1-c. Eligibility Fields

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 6.4.1-d. Eligibility Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.4.1-a. Eligibility Fields
Field

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

1. 12-month Preventive Medicine Residency
2. 24-month Preventive Medicine Residency (needs MPH)
3. 24-month Preventive Medicine Residency (does not
need MPH)
1. Yes
2. No
1. Yes
2. No
-

Yes

No
No

Yes
Yes

No
No

Yes

Evaluate a public health
surveillance system:
Give an in-depth public health talk
on your original work or in your
field of study:
Write a scientific manuscript for a
peer-reviewed journal:

Yes

Communicate complex scientific
concepts to a lay audience:

Yes

Provide epidemiologic support to a
public health agency:

Yes

1. Yes
2. No

Yes

1. Federal Employee - Title 42
2. Federal Employee - Title 5
3. Federal Employee - U.S. Public Health Service
4. Federal Employee - Military
5. Not a current Federal Employee
1. Yes
2. No

Yes

Select preventive medicine
program you are applying for:

Are you either an EIS Officer or
Alumnus?
Has your EIS experience been
within the past two years?
EIS Activity Report Upload:
Conduct or participate in a field
investigation of a potentially
serious public health problem that
requires a timely response:
Design, conduct, and interpret an
epidemiologic analysis:

Do you intend to seek certification
by the American Board of
Preventive Medicine?
What personnel system are you
currently in?

Have you applied or do you plan on
applying to be a Commissioned
Officer in the U.S. Public Health
Service within the next 6 months?

Values

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Field
What is the status of your
application?

What is the date of your
Commission?
What is your current temporary
rank?

Are you a Foreign Medical
Graduate?
Do you have any Accreditation
Council for Graduate Medical
Education (ACGME) or American
Osteopathic Association (AOA) accredited post-graduate clinical
training?
Do you have a current, full, and
unrestricted medical license from a
U.S. licensing jurisdiction?
Do you have an MPH or an
equivalent degree?
Warning: You may not be eligible
for the PMR/F. You can continue
the application if you think you are
eligible. Do you want to continue
the application?

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

1. O1
2. O2
3. O3
4. O4
5. O5
6. O6
7. O7
1. Yes
2. No

Yes

1. Yes
2. No

Yes

1. Yes
2. No

Yes

1. Yes
2. No
1. Yes
2. No

Yes

1. Pending Application
2. Accepted
3. Under Review
4. Rejected
-

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.4.2 Commissioned Corps

Figure 6.4.2-a. Commissioned Corps Fields

Table 6.4.2-a. Commissioned Corps Fields
Field
Are you currently a U.S. Public
Health Service Commissioned Corps
Officer?
Corps Rank:

Values

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
Yes

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

1. O-3 LT
2. O-4 LCDR
3. O-5 CDR
4. O-6 CAPT
5. O-7 RADM
6. O-8 RADM

Yes

1. Yes
2. No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.4.3 Public Health Work Experience

Figure 6.4.3-a. Public Health Work Experience Fields

Table 6.4.3-a. Public Health Work Experience Fields
Field
Indicate where you have had Public
Health/Population based work experience:

Values
1. National or deferral level or
CDC headquarters
2. State or local health
department
3. Both State or local health
department and National or
deferral level or CDC
headquarters
4. Other

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.5 PHIFP
6.5.1 Eligibility

Figure 6.5.1-a. Eligibility Fields

Figure 6.5.1-b. Eligibility Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.5.1-a. PHIFP - Eligibility Fields
Field
Degree level selection:

Values
1. Doctoral
2. Masters
3. None

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
Yes

PE
No

ELI
No

PHAP
No

Informatics experience selection: (1 Year)

1. Yes
2. No

Yes

Public health experience selection: (1 Year)

1. Yes
2. No

Yes

Informatics experience selection: (3 Years)

1. Yes
2. No
1. Yes
2. No
1. Yes
2. No

Yes

Public health experience selection: (3 Years)
Do you have documented experience in
performing research or evaluation during or
after academic training? This includes
publications, thesis, poster presentations, or
a research or evaluation proposal.

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.6 SAF
6.6.1 Teaching Experience
Figure 6.6.1-a. Teaching Experience Fields

Table 6.6.1-a. Teaching Experience Fields
Field
Do you have a current teaching license in your
state?
Grade Levels Ever Taught:

Specify Grade Level Taught:

Values

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
Yes

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

1. Elementary School (grades K-5)
2. Middle School (grades 6-8)
3. High School (grades 9-12)
2. Community College
3. College (Undergraduate)
4. College (Graduate)
5. Other: Curriculum
Development
6. Other: Professional
Development
7. Other (Specify)
-

Yes

1. Yes
2. No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.7 EEP
6.7.1 Academic Endorsement

Figure 6.7.1-a. Academic Endorsement Fields

Table 6.7.1-a. Academic Endorsement Fields
Field
Academic Endorsement Form:

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.8 PHAP
6.8.1 Special Requirements

Figure 6.8.1-a. Special Requirements Fields

Figure 6.8.1-b. Special Requirements Fields

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 6.8.1-c. Special Requirements Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.8.1-a. Special Requirements Fields
Field
What is the highest degree you will have attained by the start of the
program?

Values
1. Bachelor’s degree
2. Master’s degree
3. Doctorate
4. Other

EIS LLS FLIGHT EEP SAF PMR/F PH-TIPP PHIFP PE ELI PHAP
No

No No Yes

Please specify:

No No Yes

Actual or anticipated date of attained degree:

No No Yes

What is/was your overall GPA on a 4.0 scale for your highest degree
attained by the start of the program?

No No Yes

Do you have a preference in location where you are willing to relocate?
1. Yes
(Please note that your preference of location does not affect your rating or 2. No
eligibility into the program. The information, when possible, is used for
matching purposes only. There are no assignments at CDC headquarters in
Atlanta, Georgia. Most importantly, while geographic preference may be
taken into consideration, assignment offers in selected areas are not
guaranteed and are non-negotiable.)

No No Yes

1st Choice:

State/Territory Lookup

No No Yes

2nd Choice:

State/Territory Lookup

No No Yes

3rd Choice:

State/Territory Lookup

No No Yes

4th Choice:

State/Territory Lookup

No No Yes

5th Choice:

State/Territory Lookup

No No Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Please select any additional areas you would accept an assignment match:

State/Territory Lookup

No No Yes

Table 6.8.1-b. Special Requirements Fields
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Would you be willing to work in a rural
setting?

1. Yes
2. No

Yes

Would you be willing to work on an
Indian reservation?

1. Yes
2. No

Yes

Do you have a preference in the subject 1. Yes
area you would like to work on?
2. No

Yes

1st Choice:

Subject Area
Field Value Table

Yes

2nd Choice:

Subject Area
Field Value Table

Yes

3rd Choice:

Subject Area
Field Value Table

Yes

4th Choice:

Subject Area
Field Value Table

Yes

5th Choice:

Subject Area
Field Value Table

Yes

Please select any additional subject areas
you would accept an assignment match:
Do you have a valid Driver’s license from 1. Yes
a state/territory in the USA?
2. No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Do you own a car (privately owned
vehicle: POV)?

1. Yes
2. No

Yes

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Clinical Category:

1. Physician
2. Veterinarian

Yes

Have you taken FACT training?

1. Yes
2. No

Yes

6.9 FLIGHT
6.9.1 Clinical Category & Training
Figure 6.9.1-a. Clinical Category & Training Fields

Table 6.9.1-a. Clinical Category & Training Fields
Field

Training Month:

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Training Year:

Yes

6.9.2 Current EIS Position

Figure 6.9.2-a. Current EIS Position

Table 6.9.2-a. Current EIS Position.
Field
Team:
Center/Division/Branch:

Specify:

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Center/Division/Branch
Lookup

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.9.3 Current Primary Supervisor

Figure 6.9.3-a. Current Primary Supervisor

Table 6.9.3-a. Current Primary Supervisor
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

First Name:

Yes

Last Name:

Yes

CDC Email:

Yes

Work Phone:

Yes

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

6.9.4 Scientific Experience
Figure 6.9.4-a. Scientific Experience

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.9.4-a. Scientific Experience
Field
First-authored manuscripts
published in peer reviewed journals
over the last ten years:
First-authored manuscript
submitted and currently being
considered for publication in a peer
reviewed journal:
First-authored manuscripts
currently undergoing CDC
clearance:
First-authored manuscripts
currently in draft stage:

Values
-

EIS
No

LLS
No

FLIGHT
Yes

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

Yes

First-authored abstracts presented
at scientific conferences during EIS:

Yes

Awards received during EIS:

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.10

PH-TIPP

6.10.1 Eligibility

Figure 6.10.1-a. Eligibility

Table 6.10.1-a. Eligibility
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Do you have an MPH or an equivalent 1. Yes
degree?
2. No

Yes

Warning: You may not be eligible for 1. Yes
the PH-TIPP. You can continue the
2. No
application if you think you are
eligible. Do you want to continue the
application?

Yes

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

6.10.2 Program & Organization

Figure 6.10.2-a. Program & Organization

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.10.2-a. Program & Organization
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

What is the name of the program?

Yes

What is the name of the
organization?
Are you located at a CDC center?

Yes

Specify:

1. Yes
2. No
Center/Division/Branch
Lookup
-

Yes

Country:

Country Lookup

Yes

State/Territory:

State Lookup

Yes

Center/Division/Branch:

State/Province:

Yes

City:

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.10.3 Host Site Position Description

Figure 6.10.3-a. Host Site Position Description

Figure 6.10.3-b. Host Site Position Description

Attachment 3 – FMS Application Module

Figure 6.10.3-c. PH-TIPP – Host Site Position Description

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 6.10.3-d. PH-TIPP – Host Site Position Description

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.10.3-c. PH-TIPP – Host Site Position Description
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Host Agency Information: Describe
the activities of the agency, your
immediate team, and key
partnerships relevant to the projects
proposed. Describe how the agency
will support you during this trainingin-place program.

Yes

Leadership Opportunities: Summarize
opportunities for you to gain
leadership and management
experience outside of your usual
position during the training year.

Yes

SMEs and Consultants:

Yes

Education and Training Staff:

Yes

Support Staff:

Yes

Travel Funding:

Yes

Policy Analysis and Development:

Yes

Program Evaluation:

Yes

Attachment 3 – FMS Application Module

6.11

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

ELI

6.11.1 Organization Details

Figure 6.11.1-a. Organization Details Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.11.1-a. Organization Details Fields
Field
Organization Name:
Is this a public health organization?
Public Health Organization Type:

Specify Public Health Organization
Type:
Position Title:

Values
-

EIS
No
No

LLS
No
No

FLIGHT
No
No

EEP
No
No

SAF
No
No

PMR/F
No
No

PH-TIPP
No
No

PHIFP
No
No

PE
No
No

ELI
Yes
Yes

PHAP
No
No

Yes

1. Yes
2. No
1. State
2. Local
3. Territorial
4. Tribal
5. International
Health
6. University
7. Hospital
8. Other

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

6.11.2 Educational Experience

Figure 6.11.2-a. Educational Experience Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.11.2-a. Educational Experience Fields
Field
Your Highest Degree Attained:

Degree or Certification Type:

Specify Degree or Certification
Type:
Degree or Certification Transcript:

Values
1. Bachelors
2. Masters or
higher
3. Other related
Certification
4. No Degree or
Certification
1. Education
2. Public Health /
Sciences
3. Technology
4. Business
5. Other

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
Yes

PHAP
No

Yes

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

6.11.3 Work Experience

Figure 6.11.3-a. Work Experience Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.11.3-a. Work Experience Fields
Field
What is your role in the
development of training? (Select
all that apply)

Specify Role:
Do you have experience in
developing training for public
health audiences?
Please rate your experience:

How long have you been
developing e-learning?

Please describe your experience:
Approximately how many training
activities such as online courses or
webinars does your organization
create annually?
What percentage of your
organization’s training activity is elearning?

Values
1. Instructional Designer or Trainer
2. Subject Matter Expert (SME)
3. Training Coordinator
4. Learning Management (LMS)
Coordinator
5. Other
1. Yes
2. No

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
Yes

PHAP
No

No
No

Yes
Yes

No
No

1. Highly Experienced
(Degree/certification or 5 - 10 years
of experience)
2. Experienced (No degree but at
least 5 years of experience)
3. Limited Experience (No degree
and less than 5 years of experience)
1. 0 years
2. Less than 1 year
3. 1 - 2 years
4. 3 years or more

Yes

No
No

Yes
Yes

No
No

Yes

1. 1 - 10
2. 11 - 50
3. 51+
1. 0 - 25%
2. 26 - 50%
3. 51 - 75%
4. 76 - 100%

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

6.11.4 e-Learning Content Example

Figure 6.11.4-a. e-Learning Content Example Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 6.11.4-a. e-Learning Content Example Fields
Field
Select the format of your e-learning
content example submission:
Content Example Upload:
Website Link to Content Example:

Values
-

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
Yes

PHAP
No

No
No

Yes
Yes

No
No

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

6.12 EIS, LLS, FLIGHT, PE, PHIFP
6.12.1 Federal Student Loan Repayment Interest
Figure 13.6-a. EIS Federal Student Loan Repayment Interest Fields
6.12.1

6.12.2

6.12.3

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.12.4

Table 12.1 Federal Student Loan Repayment Interest
Field
Do you have U.S. Federal Student
loans?

Values

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
Yes

PE
Yes

ELI
No

PHAP
No

1.Yes
2.No

Yes

1.Yes
2.No

Yes

1.Yes
2.No

If response is No, STOP ELRPHP
questions and go to next section
6.12.2 Before applying, were you
aware of the Educational Loan
Repayment Program for Health
Professionals in which CDC/ATSDR
recruits can receive up to $50,000 a
year in loan repayment for a
minimum 2-year service
agreement?
*Only ask if answered yes to
question 6.12.1
Are you interested in Federal
student loan repayment? (To learn
more please visit the Educational
Loan Repayment for Health
Professionals information on the
website).
*Only if answered yes to question
6.12.1.
6.12.5 Did the availability of this
loan repayment program influence

1.Yes
2.No

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

your decision to apply for this
fellowship?
*Only if answered “yes” to interest
in student loan repayment (6.12.4)

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

6.12

Confirming Accuracy & Minimum Eligibility

Figure 6.12-a. Confirming Accuracy & Minimum Eligibility Fields

Table 6.12-a. Confirming Accuracy & Minimum Eligibility Fields
Field
By selecting the option
below, you confirm that
the information given in
this form is true,
complete, and accurate
and that you meet the
minimum eligibility
requirements for this
fellowship program?

Values
1. I confirm that the
information given in this
form is true, complete,
and accurate and that I
meet the minimum
eligibility.

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Figure 6.12-b. Not Eligible Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7. Education & Licenses
7.1 Adding Education or Licenses
Figure 7.1-a. Adding Education or Licenses

Table 7.1-a. Adding Education or Licenses
Field
Please include
educational background
starting with your
undergraduate
experience. Medical
and/or veterinary
school information is
required.

Values
-

EIS
No

LLS
No

FLIGHT
No

EEP
Yes

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 7.1-b. Adding Education or Licenses

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.2 Choose Category
Figure 7.2-a. Choose Category Fields

Table 7.2-a. Choose Category Fields
Field
Do you want to proceed?
What do you want to add?

Values
1. Yes
1. Undergraduate
Education
2. Graduate Education
3. Additional
Coursework
4. Active U.S. License

EIS
Yes
Yes

LLS
Yes
Yes

FLIGHT
Yes
Yes

EEP
Yes
Yes

SAF
Yes
Yes

PMR/F
Yes
Yes

PH-TIPP
Yes
Yes

PHIFP
Yes
Yes

PE
Yes
Yes

ELI
No
No

PHAP
Yes
Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.3 Coursework Type
Figure 7.3-a. Coursework Type Fields

Table 7.3-a. Coursework Type Fields
Field
Which type of coursework
do you need to add?

Values
-

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
Yes

PH-TIPP
Yes

PHIFP
No

PE
No

ELI
No

PHAP
No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.4 Location
Figure 7.4-a. Location Fields

Table 7.4-a. Location Fields
Field
Country:
State/Province:

Values
-

EIS
Yes
Yes

LLS
Yes
Yes

FLIGHT
Yes
Yes

EEP
Yes
Yes

SAF
Yes
Yes

PMR/F
Yes
Yes

PH-TIPP
Yes
Yes

PHIFP
Yes
Yes

PE
Yes
Yes

ELI
No
No

PHAP
Yes
Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.5 College/University
Figure 7.5-a. College/University Fields

Table 7.5-a. College/University Fields
Field
College/University:
College/University:
If your college/university is
not listed, please contact
the System Help Desk Ticket

Values
College Lookup
-

EIS
Yes
Yes
Yes

LLS
Yes
Yes
Yes

FLIGHT
Yes
Yes
No

EEP
Yes
Yes
Yes

SAF
Yes
Yes
Yes

PMR/F
Yes
Yes
No

PH-TIPP
Yes
Yes
No

PHIFP
Yes
Yes
No

PE
Yes
Yes
No

ELI
No
No
No

PHAP
Yes
Yes
No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.6 Status
Figure 7.6-a. Status Fields

Table 7.6-a. Status Fields
Field
Degree Status:

Values
1. Current (Ongoing)
2. Graduated (Degree program)
3. Completed (Nondegree
program)
4. Did not complete

Has your degree been 1. Yes
conferred?
2. No

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Course Status:

1. Current
2. Completed

Yes

License Status:

1. Expected
2. Received

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.7 Degree
Figure 7.7-a. Degree Fields

Figure 7.7-b. Degree Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 7.7-a. Degree Fields
Field
Undergraduate Degree:
Graduate Degree:
Other Degree:
Major 1:
Major 1 Classification:
Is this degree a double
major?
Major 2:
Major 2 Classification:
Minor/Certificate/Specialty:
Grade Point Average (GPA):
Did you complete a thesis
or dissertation?
Title & Abstract:
Did you receive academic
honors?
Honor Types:
Transcript Upload:
MPH Certificate Upload:
Please acknowledge that
you have uploaded a
foreign credential
evaluation for transcript
issued by a non-U.S.
institution.

Values
Undergraduate Degree List
Graduate Degree List
Major Classification List
-

EIS
Yes
Yes
Yes
Yes
Yes
Yes

LLS
Yes
Yes
Yes
Yes
Yes
Yes

FLIGHT
Yes
Yes
Yes
No
No
No

EEP
Yes
Yes
Yes
Yes
Yes
Yes

SAF
Yes
Yes
Yes
Yes
Yes
Yes

PMR/F
No
Yes
Yes
Yes
Yes
Yes

PH-TIPP
No
Yes
Yes
Yes
Yes
Yes

PHIFP
No
Yes
Yes
Yes
Yes
Yes

PE
No
Yes
Yes
Yes
No
No

ELI
Yes
Yes
Yes
Yes
Yes
No

PHAP
Yes
Yes
Yes
Yes
Yes
Yes

Major Classification List
-

Yes
Yes
Yes
Yes
Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
No
No

Yes
Yes
Yes
No
Yes

Yes
No
Yes
No
Yes

No
No
No
Yes
No

Yes
Yes
Yes
Yes
Yes

Yes
Yes

No
No

Yes
Yes

No
No

Yes
Yes

Yes
No

No
No

Yes
Yes

Yes
Yes
No
No

Yes
Yes
No
Yes

No
No
No
No

Yes
No
No
No

No
No
No
No

Yes
No
Yes
No

Yes
No
No
No

No
Yes
No
No

No
No
No
No

Yes
Yes
No
No

1. Yes
2. No
Honor List
1. Yes
2. No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.8 Additional Coursework
Figure 7.8-a. Additional Coursework Fields

Table 7.8-a. Additional Coursework Fields
Field
Number of Credits:
Course Name:

Values
-

EIS
No
No

LLS
No
No

FLIGHT
No
No

EEP
No
No

SAF
No
No

PMR/F
Yes
Yes

PH-TIPP
Yes
Yes

PHIFP
No
No

PE
No
No

ELI
No
No

PHAP
Yes
Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.9 License
Figure 7.9-a. License Fields

Table 7.9-a. License Fields
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

State Lookup Table

Yes

License Number:

Yes

License Upload:

Yes

Issuing State:

Attachment 3 – FMS Application Module

7.10

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Dates

Figure 7.10-a. Date Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 7.10-a. Date Fields
Field
Attended From:

Values
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
No

PHAP
Yes

Attended To:

Yes

Expected Completion Date:
Degree Conferral Date:

Yes
Yes

No
No

Yes
Yes

No
No

Yes
Yes

PhD Defense Date:
License Expected Date:
License Received Date:
License Expiration Date:

Yes
Yes
Yes
Yes

No
Yes
Yes
Yes

No
No
No
No

Yes
Yes
Yes
Yes

Yes
No
No
No

No
No
No
No

Yes
No
No
No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

7.11

Incomplete Reason

Figure 7.11-a. Incomplete Reason Field

Table 7.11-a. Incomplete Reason Field
Field
Incomplete Reason:

Values
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
No

PHAP
Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

8. Work & Volunteer Experience
8.1 Adding Work or Volunteer Experience
Figure 8.1-a. Adding Work or Volunteer Experience

Figure 8.1-b. Adding Work or Volunteer Experience

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

8.2 Choose Category
Figure 8.2-a. Choose Category Fields

Table 8.2-a. Choose Category Fields
Field
Do you want to
proceed?
What do you want to
add?

Values
1. Yes
1. Work Experience
2. Volunteer Experience

EIS
Yes

LLS
Yes

FLIGHT
No

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
No

PHAP
No

Yes

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

8.3 Organization Details
Figure 8.3-a. Organization Details Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 8.3-a. Organization Details Fields
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

Organization Name

Yes

Organization Type

1. Additional education or training (including degree or residency
programs, fellowships and post-doctoral research positions)
2. Government – CDC (including contractor work)
3. Government – non-CDC federal government (including
contractor work)
4. Government – state, tribal, local, or territorial health agency
(including contractor work)
5. Non-governmental, community, or other organization (NGO)
6. Academia (as faculty or staff)
7. Industry (private, non-clinical business)
8. Clinical work

Yes

Does your organization, 1. Yes
school or school district 2. No
receive Title 1 financial 3. N/A
assistance?

Yes

May we contact your
supervisor?

Yes

1. Yes
2. No

PMR/F PH-TIPP PHIFP

ELI

PHAP

Yes

Supervisor Name

Yes

Supervisor Phone
Number

Yes

Supervisor Email

Yes

Reason

Yes

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

8.4 Position Details
Figure 8.4-a. Position Details Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 8.4-a. Position Details Fields
Field
Title
Hours Per Week
Is this position related
to public health?
Duties and
Responsibilities
Accomplishments
Extracurricular
Duties/Responsibilities
(e.g., advisor, board
member, committee
chair, coach, teacher
association president)
Full-time or part-time?

Values
-

EIS
Yes
Yes
Yes

LLS
Yes
Yes
Yes

FLIGHT
No
No
No

EEP
Yes
Yes
Yes

SAF
Yes
No
No

PMR/F
Yes
Yes
Yes

PH-TIPP
Yes
Yes
Yes

PHIFP
Yes
Yes
Yes

PE
Yes
Yes
Yes

ELI
No
No
No

PHAP
No
No
No

Yes

Yes
No

No
No

No
Yes

Yes
No

No
No

Yes

1. Yes
2. No

1. Part Time (<30 hours per week)
2. Full Time (>30 hours per week)

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

8.5 Dates
Figure 8.5-a. Date Fields

Table 8.5-a. Date Fields
Field
Dates From
Is this a current
position?
Dates To
Reason for Leaving

Values
-

EIS
Yes
Yes

LLS
Yes
Yes

FLIGHT
No
No

EEP
Yes
Yes

SAF
Yes
Yes

PMR/F
Yes
Yes

PH-TIPP
Yes
Yes

PHIFP
Yes
Yes

PE
Yes
Yes

ELI
No
No

PHAP
No
No

Yes
Yes

No
No

Yes
Yes

No
No

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

8.6 Position Location
Figure 8.6-a. Position Location Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 8.6-a. Position Location Fields
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F PH-TIPP PHIFP

ELI

PHAP

Address

Yes

Address Line 2

Yes

Address Line 3

Yes

Country

Country Lookup Table

Yes

State/Territory:

State Lookup Table

Yes

State/Province

Yes

City

Yes

Zip/Postal Code

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

9. Additional Training & Skills
9.1 Adding Additional Training & Skills

Figure 9.1-a. Adding Additional Training & Skills

Figure 9.1-b. Adding Additional Training & Skills

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

9.2 Choose Category
Figure 9.2-a. Choose Category Fields

Table 9.2-a. Choose Category Fields
Field
Do you want to proceed?

Values
1. Yes

What do you need to add? 1. Clinical Training
2. U.S. Board Certification
3. Additional Training,
Certification or Professional
Development
4. Language Skill
5. None of the Above

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

9.3 Clinical Training
Figure 9.3-a. Clinical Training Fields

Table 9.3-a. Clinical Training Fields
Field

Values
-

Title:
May we contact your
supervisor?
Supervisor Name:
Supervisor Email:
Supervisor Phone
Number:
Reason:

EIS
Yes

LLS
Yes

FLIGHT
No

EEP
No

SAF
No

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
No

ELI
No

PHAP
No

Yes

Yes
Yes
Yes

No
No
No

Yes
Yes
Yes

No
No
No

Yes

1. Yes
2. No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

9.4 U.S. Board Certifications and Specialty
Figure 9.4-a. Clinical Training Fields

Table 9.4-a. Clinical Training Fields
Field
Status:
Specialty:
Specify Specialty:

Values
1. Certified
2. Eligible
Specialty Lookup Table
-

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
No

SAF
No

PMR/F
Yes

PH-TIPP
Yes

PHIFP
No

PE
No

ELI
No

PHAP
No

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

9.5 Additional Training, Certifications, or Professional Development
Figure 9.5-a. Additional Training, Certifications, or Professional Development Fields

Table 9.5-a. Additional Training, Certifications, or Professional Development Fields
Field
Training Name:
Description:
Certification Upload:

Values
-

EIS
Yes
Yes
Yes

LLS
Yes
Yes
Yes

FLIGHT
No
No
No

EEP
Yes
Yes
No

SAF
Yes
Yes
No

PMR/F
Yes
Yes
Yes

PH-TIPP
Yes
Yes
Yes

PHIFP
Yes
Yes
Yes

PE
Yes
Yes
Yes

ELI
No
No
No

PHAP
No
No
No

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

9.6 Institution Details and Location
Figure 9.6-a. Institution Details and Location Fields

Table 9.6-a. Institution Details and Location Fields
Field
Institution Name:

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Country:

Country Lookup Table

Yes

State/Territory:

State/Territory Lookup Table

Yes

State/Province:

Yes

City:

Yes

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

9.7 Dates
Figure 9.7-a. Date Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 9.7-a. Date Fields
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Dates From:

Yes

Are you currently pursuing?

Yes

Dates To:

Yes

Expected Date:

Yes

Most Recent Issuance Date:

Yes

Most Recent Expiration
Date:

Yes

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

9.8 Language Skills
Figure 9.8-a. Language Skill Fields

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 9.8-a. Language Skill Fields
Field
Language:

Values
Languages Lookup Table

Other Language:

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Read:

1. Poor
2. Fair
3. Good
4. Excellent

Yes

Write:

1. Poor
2. Fair
3. Good
4. Excellent

Yes

Speak:

1. Poor
2. Fair
3. Good
4. Excellent

Yes

Attachment 3 – FMS Application Module

10.

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Publications, Presentations, Working Papers, Monographs or Reports,
Grants, Honors and Awards

10.1
Adding Publications, Presentations, Working Papers, Monographs or Reports, Grants, Honors and
Awards
Figure 10.1-a. Adding Publications, Presentations, Working Papers, Monographs or Reports, Grants, Honors and Awards

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 10.1-b. Adding Publications, Presentations, Working Papers, Monographs or Reports, Grants, Honors and Awards

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

10.2

Choose Category

Figure 10.2-a. Choose Category Fields

Table 10.2-a. Choose Category Fields
Field
Do you want to proceed?

Values
1. Yes

What do you want to add? 1. Publications
2. Presentations
3. Grants
4. Honor or Awards
5. Monographs or Reports
6. Research Grants
7. Working Papers (Job
Market Papers)

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

10.3

Details

Figure 10.3-a. Detail Fields

Figure 10.3-b. Detail Fields

100

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 10.3-a. Detail Fields
Field
Details:

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

101

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

11.
11.1

Personal Statement

All Fellowships except FLIGHT

Figure 11.1-a. Personal Statement Fields

102

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

103

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 11.1-b. Personal Statement Fields

104

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Figure 11.1-a. Personal Statement Fields
Field
What influenced you to consider a career in public health
service?
Describe how this fellowship/program will help you achieve
your goals.
Why are you interested in this fellowship/program?
What makes you a good candidate for this
fellowship/program?
Why do you want to join the CDC?
How do your values align with the core CDC values?
Understanding that there are different topical and
geographical assignments, in which do you prefer to work and
why?
How do you anticipate using the concepts and skills learned in
this fellowship/program? Be as specific as possible.

Values
-

Describe the two most important skills you want to develop or
improve during this fellowship/program.

What do you believe are facilitators at your organization for
developing e-learning?

What do you believe are barriers at your organization for
developing e-learning?
Describe your proficiency using e-learning software. Include
the authoring tool/s used at your current organization.
What is your experience incorporating new content into your
curricula? Please provide at least one example.
Describe your experience related to data management and
analysis, including the use of statistical software packages
such as Excel, SAS, STATA, R, or Epi Info. Please provide
specific examples. Note that this question will be used to
assist the program with matching applicants to appropriate
host sites.
For re-applicants: When did you apply and what has changed
since your last application?

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

No
No

Yes
No

No
No

No
Yes

Yes

105

Attachment 3 – FMS Application Module

11.2

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

FLIGHT

Figure 11.2-a. FLIGHT Personal Statement Fields

106

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 11.2-a. FLIGHT Personal Statement Fields
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

1. Tell us the characteristics, skills, and abilities that
make you the best candidate for this scientific
leadership program.

Yes

2. Tell us what the two most important skills you want
to develop or improve after finishing EIS.

Yes

3. Elaborate on your most significant accomplishment
during your EIS fellowship.

Yes

4. Describe the biggest challenge you faced during EIS,
and how you overcame that challenge.

Yes

5. Tell us your career goals after graduating from this
leadership program, and how this leadership program
will help you achieve them.

Yes

107

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

11.3 Location Preferences
Figure 11.3-a. Location Preference Fields

108

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 11.3-a. Location Preference Fields
Field
What is your preference for location of
assignment?

State/Territory Preference(s):
Do you have geographic constraints on
where you can relocate for your
fellowship/program?
Please explain:

Values
1. I am only interested in CDC
Headquarters assignments.
2. I am only interested in state
assignments
3. I am interested in CDC
Headquarters assignments and
state assignments.
State/Territory List
1. Yes
2. No
-

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

109

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

11.4 CDC Fellowship Participation

110

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 11.4. CDC Fellowship Participation Fields

111

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

112

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

113

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 11.3-a. CDC Fellowship Participation Fields
Field
Have you participated in any CDC fellowship
programs?

Values
1. Yes
2. No

Please select all CDC fellowships that you
have participated in:

CDC Fellowship
List

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

114

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

12.
12.1

Standardized Letters of Recommendation (SLOR)

SLOR Requests

12.1.1 Starting a SLOR Request
Figure 12.1.1-a. Starting a SLOR Request

Figure 12.1.1-a. Starting a SLOR Request

115

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

12.1.2 SLOR Request Fields

Figure 12.1.2-a. SLOR Request Fields

Figure 12.1.2-b. SLOR Request Fields

116

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 12.1.2-a. LOR Request Fields
Field
Recommender's Name:
Organization:
Job Title:
Dean of Medical School?
Phone:
Email:
Relationship to you:
Note to the recommender:
You confirm that your
supervisor is aware and in
support of your application
to this fellowship?

Values
1. Yes
1. Yes, I confirm

EIS
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

LLS
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No

FLIGHT
Yes
No
Yes
No
Yes
Yes
Yes
Yes
No

EEP
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

SAF
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No

PMR/F
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

PH-TIPP
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

PHIFP
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

PE
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

ELI
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes

PHAP
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No

117

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

You confirm that your
supervisor is aware that the
deliverable of this
fellowship is an e-learning
product that takes less than
20 minutes to complete and
that your product must be
submitted at the end of the
fellowship and listed on the
TRAIN network?

1. Yes, I confirm

Yes

Letter of Recommendation
Waiver Agreement:

1. "In order to be
considered for the
fellowship program, I
agree to waive my
right to view any
recommendations
submitted for me."
-

Yes

Two of the standardized
letters of recommendation
must be from persons who
are not currently employed
at the CDC.
If you are currently
employed at CDC, you may
request a fourth letter if, in
addition to 2 letters from
non-CDC employees, you
would like to submit 2
letters from current CDC
employees.
-Recommenders should
typically be current or
former supervisors or
professors. Avoid
requesting letters from
colleagues or friends.
-Recommendations must be
written in English.

118

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

-Let recommenders know
you are requesting a
recommendation and tell
them to expect an email
with a link to the online
form that they should use
to complete the
standardized letter of
recommendation.
Traditional narrative letters
of recommendation and
MSPE (Dean’s letter format)
are not accepted.

119

Attachment 3 – FMS Application Module

12.2

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

System Emails to Letter Writers

120

Attachment 3 – FMS Application Module

12.3

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Letters of Recommendation

12.3.1 Section A

Figure 12.3.1-a. Section A Fields

121

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Figure 12.3.1-a. Section A Fields
Field
Name of person submitting the recommendation
form:
Title of person submitting the recommendation
form:
Organization name:

Values

Phone number:
Number of persons with similar background to the
candidate that you supervised over last 5 years:

Name of person for whom this recommendation is
being submitted:
In what role are you providing this reference?

Explain:

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Yes

1. <= 1
2. 2 - 5
3. 6 - 10
4. > 10
1. Supervisor
2. Advisor
3. Program director
4. Dean
5. Professor
6. Faculty member
7. Thesis committee
member
8. Other (Explain)
-

Yes

How long have you known the candidate?

Yes

Describe your role working or collaborating with
this person:
On average, how often have you worked with, or
do you work with, the candidate (For example:
average of 5 days per week over the past 6
months, or occasional interaction over the past 10
years).

Yes

122

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

12.3.2 Section B

Figure 12.3.2-a. Section B Fields

123

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Table 12.3.2-a. Section B Fields
Field
Compared with other similar individuals you have
supervised or advised, how do you rank this
candidate at developing effective working
relationships with a variety of different people?

Please provide an example(s) about this
candidate’s experience developing effective
working relationships, e.g., with internal or
external partners, team members, or state/local
health professionals.
Compared with other similar individuals you have
supervised or advised, how do you rank this
candidate at managing tasks or projects?

Please provide an example that describes the
effectiveness of task or project management, e.g.,
was management of tasks and projects timely,
complete, and responsive.

Values
1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

EIS
Yes

LLS
Yes

FLIGHT
No

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
No

PE
No

ELI
Yes

PHAP
Yes

Yes

1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

Yes

124

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Attachment 3 – FMS Application Module

Table 12.3.2-b. Section B Fields
Field
Compared with other similar individuals you have
supervised or advised, how do you rank this
candidate at effectively prioritizing efforts?

Please provide an example that describes the
effective prioritization of efforts, e.g., could this
candidate identify and act on the most important
tasks first?
Compared with other similar individuals you have
supervised or advised, how do you rank this
candidate’s ability to take initiative?

Please provide an example that describes the
candidate’s ability to take initiative, e.g., did this
person actively seek to identify issues and address
them without being told?
Compared with other similar individuals you have
supervised or advised, how well did this candidate
respond to constructive feedback?

Please provide an example(s) of how the
candidate responded to constructive feedback.
This could include feedback on e.g., their
performance, behavior, or scientific work.

Values
1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

EIS
Yes

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
Yes

PH-TIPP
Yes

PHIFP
No

PE
No

ELI
Yes

PHAP
No

Yes

1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

Yes

1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

Yes

125

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Attachment 3 – FMS Application Module

Table 12.3.2-b. EIS Section B Fields

Table 12.3.2-a. Section B Fields
Field
Compared to other individuals at a similar point in
their careers, how do you rank this candidate at
developing effective working relationships with a
variety of different people?

Values
1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)

EIS
Yes

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

126

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Attachment 3 – FMS Application Module

Please provide an example(s) about this
candidate’s experience developing effective
working relationships with a variety of different
people?
Compared to other individuals at a similar point in
their careers, how do you rank this candidate at
managing tasks or projects?

Please provide an example that describes the
effectiveness of task or project management, e.g.,
was management of tasks timely, complete, and
responsive?
Compared to other individuals at a similar point in
their careers, how do you rank this candidate at
effectively prioritizing efforts?

Compared to other individuals at a similar point in
their careers, how do you rank this candidate’s
ability to take initiative?

Compared to other individuals at a similar point in
their careers, how well did this candidate respond
to constructive feedback?

4. Superior (Top 2%)
5. Not able to judge
-

Yes

1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

Yes

1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge

Yes

127

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 12.3.2-b. Section B Fields

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Attachment 3 – FMS Application Module

Table 12.3.2-c. Section B Fields
Field
Compared with other similar individuals you have
supervised or advised, how do you rank the
candidate’s knowledge of health data, methods,
and analytics?

Please provide an example(s) of the candidate’s
knowledge of health data, methods, and analytics.
Compared with other similar individuals you have
supervised or advised, how do you rank the
candidate’s flexibility and resilience?

Please provide an example(s) of the candidate’s
flexibility and resilience.
Compared with other similar individuals you have
supervised or advised, how do you rank the
candidate’s self-advocacy?

Please provide an example(s) when the candidate
advocated successfully on behalf of themselves
and their work.
Do you have any concerns about this applicant
and their potential performance in this
fellowship/program?
Explain the strongest reason/s that we should
consider for selecting this candidate.

Values
1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

EIS
No

LLS
No

FLIGHT
No

EEP
Yes

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
Yes

ELI
No

PHAP
No

Yes

1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

Yes

1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

Yes

129

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Attachment 3 – FMS Application Module

Table 12.3.2-b. PHAP Section B Fields

Table 12.3.2-b. PHAP Section B Fields
Field
Compared with other similar individuals you have
supervised or advised, how do you rank the
candidate’s integrity?

Please provide an example(s) that describes
his/her integrity, e.g., demonstration of honesty
and candor, or witnessed an instance where the
candidate lied to avoid or delay consequences.

Values
1. Average (75% or
below)
2. Above Average
(Top 25%)
3. Excellent (Top 10%)
4. Superior (Top 2%)
5. Not able to judge
-

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
Yes

Yes

130

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

12.3.3 Section C

Figure 12.3.3-a. Section C Fields

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Attachment 3 – FMS Application Module

Table 12.3.3-a. Section C Fields
Field
As a candidate for this fellowship/program, I
consider the applicant:

Values
1. Not suitable
2. Minimally suitable
3. Suitable
4. Very suitable
5. Most suitable

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Please describe the specific skills and attributes of
the candidate that make them suitable for this
fellowship/program:
Any other comments:

Yes

Enter your initials:

Yes

Enter today's date:

Yes

132

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Attachment 3 – FMS Application Module

13.

Final Application Sections

13.1 Self-Assessment of Skills
13.1.1 PHIFP
Figure 13.1.1-a. PHIFP Self-Assessment of Skills Fields

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Attachment 3 – FMS Application Module

Table 13.1.1-a. PHIFP Self-Assessment of Skills Fields
Field
1. Data Sciences (Wrangling, Cleansing, Modeling,
Analytics):

Data Sciences Experience:
2. Data Science Methods (e.g. machine learning, NLP, deep
learning):

Data Science Methods Experience:
3. DataViz (Storytelling using Data, DataViz methods and
tools, Dashboard design):

DataViz Experience:
4. Database Design and Development (Big Data, data
modeling, information retrieval):

Database Design and Development Experience:
5. Programming Languages and Scripting (Python, R, C, C++,
Java, Scala, C#, JavaScript, PHP):

Programming Languages and Scripting Experience:
6. Distributed Computing (Cloud Computing, Grid
computing):

Distributed Computing Experience:

Values
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert
-

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

134

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 13.1.1-b. PHIFP Self-Assessment of Skills Fields

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Attachment 3 – FMS Application Module

Table 13.1.1-d. PHIFP Self-Assessment of Skills Fields
Field
7. Design Thinking (UI design, Prototyping, Human Computer
Interaction):

Design Thinking Experience:
8. Systems Engineering (Concept Development,
Requirements Engineering, System Architecture, System
Design and Development, Systems Integration, Testing,
Implementation, Compliance tracking and Certification):
Systems Engineering Experience:
9. Project Management (Project Scoping, Risk Management,
Project Management tools):

Project Management Experience:
10. Data Exchange and Interoperability (Data and Systems
standards, HL7, LOINC, SNOMED, Vocabulary Standards,
Concept Dictionaries, Ontologies):

Data Exchange and Interoperability Experience:
11. Public Health Information Systems (Clinical/PH decision
support systems, Electronic Health Records, outbreak
management systems, surveillance systems; ODK, DHIS2,
REDCap, GIS, EpiInfo):
Public Health Information Systems Experience:
12. Emerging Technologies (Blockchain and Distributed
Ledger Technologies, Artificial Intelligence, Sensor
Technologies):

Emerging Technologies Experience:

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

136

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

13.1.2 PE

Figure 13.1.2-a. PE Self-Assessment of Skills Fields

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Attachment 3 – FMS Application Module

Table 13.1.2-a. PE Self-Assessment of Skills Fields
Field
STATA:

SAS:

MATLAB:

Excel:

Values
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

Yes

1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

Yes

1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

Yes

1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

Yes

138

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Figure 13.1.2-b. PE Self-Assessment of Skills Fields

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Attachment 3 – FMS Application Module

Table 13.1.2-b. PE Self-Assessment of Skills Fields
Field
Other Software #1:
Other Software #1 Skill Level:

Other Software #2:
Other Software #2 Skill Level:

Other Software #3:
Other Software #3 Skill Level:

Values
1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

EIS
No

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
Yes

ELI
No

PHAP
No

Yes

1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

Yes

1. Novice
2. Advanced Beginner
3. Competent
4. Proficient
5. Expert

Yes

140

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Attachment 3 – FMS Application Module

Figure 13.1.2-c. PE Self-Assessment of Skills Fields

Figure 13.1.2-c. PE Self-Assessment of Skills Fields
Field
List the data sets where you have
Competent, Proficient, or Expert experience
and indicate your level experience for each.
(Competent, Proficient, or Expert):

Values
-

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

141

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

13.2 Applicant Survey
Figure 13.2-a. Applicant Survey Fields

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Attachment 3 – FMS Application Module

Table 13.2-a. Applicant Survey Fields
Field
Do you want to proceed?
How did you find out
about the Fellowship?
(Select all that apply)
*Include an open-ended
box that asks to please
specify

Values
1. Yes
1.Word of Mouth (e.g., professor, mentor,
supervisor, fellow, alumni)
2.Social Media (e.g., Facebook, LinkedIn, Instagram,
Twitter, YouTube)
3.Internet search for job or fellowship opportunities
4.Job search platform (e.g., Handshake, Indeed, JOE,
USAJobs, INFORMS)
5.Digital media advertisement (online ad clicked on
for more information)
6.Newsletter or Email Listserv
7.Print or News Media (e.g. news sources, books,
journals)
8.Other (specify)

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
Yes

PMR/F
Yes

PH-TIPP
Yes

PHIFP
Yes

PE
Yes

ELI
Yes

PHAP
Yes

Yes

143

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Attachment 3 – FMS Application Module

Specify:
How did you connect
with the person who told
you about the fellowship
by word of mouth?
(Select all that apply)
*Include an open-ended
box that asks to please
specify *If they selected
word of mouth from
13.2.a question above.
On what job search
platform did you find out
about the fellowships?
*Only if job search
platform is selected from
question 13.2.a.
What other opportunities
(e.g. jobs, fellowships,
etc.) are you considering?

1.Handshake (e.g., webinar, email, fellowship
ambassador)
2.University event, webinar, presentation
3.CDC event, webinar, presentation, booth
4.Other event, webinar, presentation (specify)
5.Professional or academic setting (e.g., professor,
mentor/supervisor, colleague)
6.Other (specify)

1.Handshake
2.Indeed
3.JOE (Job Openings for Economists
4.USAJobs
5.INFORMS
6.Other (specify)
-

Yes

144

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Attachment 3 – FMS Application Module

Table 13.2-b. LLS Applicant Survey Fields

Field
What would make the LLS program more
attractive to you? (select all that apply)

Values
1. A longer fellowship term (e.g., 3
years)
2. A fellowship term that includes
time spent at both a field (state or
local lab) and CDC headquarters
host site laboratory
3. Field experiences that require
extended (e.g., 3 to 6 months)
stays away from the host site
laboratory (e.g., outside Atlanta if
hosted at CDC headquarters)
4. Nothing
5. Other, please explain
___________.

EIS

LLS

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

Yes

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

Figure 13.2-b. Applicant Survey Fields – My Demographics
Field
What is your Ethnicity?

Values
-- Hispanic or Latino
-- Not Hispanic or Latino

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Attachment 3 – FMS Application Module

What is your Race? (select all that apply):

-- American Indian or Alaska
Native
-- Asian
-- Black or African American
-- Native Hawaiian or Other
Pacific Islander
-- White

Yes

146

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

13.3 EEP Rotation Preferences & Topic/Subject Areas
13.3.1 Rotation Preferences
Figure 13.3.1-a. Rotation Preference Fields

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Attachment 3 – FMS Application Module

Table 13.3.1-a. Rotation Preference Fields
EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Rotation A:

Field
1. Yes
2. No

Values

Yes

Rotation B:

1. Yes
2. No

Yes

Rotation C:

1. Yes
2. No

Yes

Rotation D:

1. Yes
2. No

Yes

148

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

13.3.2 Topic & Subject Areas
Figure 13.3.2-a. Topic & Subject Area Fields

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Attachment 3 – FMS Application Module

Table 13.3.2-a. Topic & Subject Area Fields
Field
Topic Area(s):

Specify:

Values
1. Obesity, nutrition, and physical activity
2. Cancer prevention and control
3. Diabetes
4. Heart disease and stroke prevention
5. Tobacco prevention and cessation
6. Other chronic disease
7. Emergency preparedness and response
8. Asthma and air pollution
9. Environmental health
10. Immunizations/vaccine preventable disease
11. Influenza
12. HIV/AIDS or Tuberculosis
13. Viral hepatitis
14. Foodborne Disease
15. Waterborne diseases
16. Vectorborne disease
17. One Health and zoonotic disease
18. Arctic Investigations (Alaska)
19. Healthcare-associated infections
20. Quarantine and border health services
21. Unintentional injury
22. Opioid/prescription drug overdose prevention
23. Occupational health and safety
24. Violence Prevention
25. Maternal and infant health
26. Health statistics
27. State, local, and territorial health
28. Global health
29. Other:
-

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

150

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Attachment 3 – FMS Application Module

Table 13.3.2-b. Topic & Subject Area Fields
Field
Project Type:

Specify:

Values
1. Data collection
2. Data entry
3. Data analysis
4. Intervention/program planning
5. Intervention/program implementation
6. Intervention/program evaluation
7. Literature review
8. Scientific writing (e.g., drafting a section of a report)
9. Communications/design (e.g., developing flyers,
website content)
10. Field investigation
11. Other:
-

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

151

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

13.3.3 Location Preferences
Figure 13.3.3-a. Location Preference Fields

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Table 13.3.3-a. Location Preference Fields
Field
What is your
preference for
the location of
your project
assignment?
(Select all that
apply)
Other CDC
Regional
Campuses
(Select all that
apply):

Other Federal
Agencies
(Select all that
apply):
State, local, or
territorial
health
departments
(Select all that
apply):

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

1. CDC headquarters or Atlanta regional campuses (Atlanta, Georgia)
2. Other CDC Regional Campuses
3. Other Federal Agencies
4. State, local, or territorial health departments

Yes

1. Anchorage, Alaska
2. Ft. Collins, Colorado
3. San Juan, Puerto Rico
4. Hyattsville, Maryland
5. Morgantown, West Virginia
6. Cincinnati, Ohio
7. Washington, DC
National Park Service (Ft. Collins, Colorado)
Indian Health Service (varies)

Yes

State/Territory List

Yes

153

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Exp. Date 03/31/2023

13.4 SAF Public Health Interests
Figure 13.4-a. SAF Public Health Interests Fields

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Attachment 3 – FMS Application Module

Table 13.5-a. SAF Public Health Interests Fields
Field
First [Second | Third]
Choice Area

Other First [Second | Third]
Choice Area

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes

155

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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

13.5 EIS CIO Assignment Interests
Figure 13.5-a. EIS CIO Assignment Interests

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Attachment 3 – FMS Application Module

Table 13.5-a. EIS CIO Assignment Interests
Field

Values

1st CDC Centers, 1. Center for Global Health
Institute, Offices 2. National Center for Chronic Disease Prevention and Health Promotion
(CIOs):
3. National Center for Emerging and Zoonotic Infectious Diseases
4. National Center for Environmental Health/Agency for Toxic Substances and Disease Registry
5. National Center for Health Statistics
6. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
7. National Center for Immunization and Respiratory Diseases
8. National Center for Injury Prevention and Control
9. National Center on Birth Defects and Developmental Disabilities
10. National Institute for Occupational Safety and Health
11. Office of Public Health Preparedness and Response

EIS LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Yes No

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Attachment 3 – FMS Application Module
2nd CDC Centers, 1. Center for Global Health
Institute, Offices 2. National Center for Chronic Disease Prevention and Health Promotion
(CIOs):
3. National Center for Emerging and Zoonotic Infectious Diseases
4. National Center for Environmental Health/Agency for Toxic Substances and Disease Registry
5. National Center for Health Statistics
6. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
7. National Center for Immunization and Respiratory Diseases
8. National Center for Injury Prevention and Control
9. National Center on Birth Defects and Developmental Disabilities
10. National Institute for Occupational Safety and Health
11. Office of Public Health Preparedness and Response

Yes No

3rd CDC Centers, 1. Center for Global Health
Institute, Offices 2. National Center for Chronic Disease Prevention and Health Promotion
(CIOs):
3. National Center for Emerging and Zoonotic Infectious Diseases
4. National Center for Environmental Health/Agency for Toxic Substances and Disease Registry
5. National Center for Health Statistics
6. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
7. National Center for Immunization and Respiratory Diseases
8. National Center for Injury Prevention and Control
9. National Center on Birth Defects and Developmental Disabilities
10. National Institute for Occupational Safety and Health
11. Office of Public Health Preparedness and Response

Yes No

EIS CIO
Assignment
Interests

1. Are you applying as a sponsored candidate by a branch of the military? Yes/No.
Yes No

EIS CIO
Assignment
Interests

By selecting the option below, you confirm that the application information given in this form is
true, complete, and accurate.
Yes No

2. If yes, specify (text box)

159

Attachment 3 – FMS Application Module

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OMB No. 0920-0765
Exp. Date 03/31/2023

13.6. Writing Samples
13.6.1 EIS Writing Samples
Figure 13.6.1-a. EIS Writing Sample Fields

160

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Attachment 3 – FMS Application Module

Table 13.6.1-a. EIS Writing Sample Fields
Field

Values

EIS

LLS

FLIGHT

EEP

SAF

PMR/F

PH-TIPP

PHIFP

ELI

PHAP

Writing Sample:

Yes

I affirm that I have not given or received
any unauthorized help on this Writing
Assessment, and that this work is my
own.

Yes

14.

Match

14.1

Match or Prematch Rank/Rating Form

General Deferment

Field Name
[REASON FOR DEFERMENT] I can no
longer participate. Please explain or
specify.

Values
-

EIS
Yes

LLS
Yes

FLIGHT
No

EEP
Yes

SAF
Yes

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

161

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Attachment 3 – FMS Application Module

Figure 15.1-a. Match or Prematch Rank/Rating Form Fields

Table 15.1-a. Match or Prematch Rank/Rating Form Fields
Field Name
Rank:
Post Match Rank:
Rating:
Comments:

Values
First Choice - Tenth Choice
First Choice - Tenth Choice
First Choice - Tenth Choice
-

EIS
Yes
Yes
Yes
Yes

LLS
Yes
Yes
Yes
Yes

FLIGHT
Yes
Yes
Yes
Yes

EEP
Yes
Yes
Yes
Yes

SAF
No
No
No
No

PMR/F
Yes
Yes
Yes
Yes

PH-TIPP
No
No
No
No

PHIFP
Yes
Yes
Yes
Yes

PE
Yes
Yes
Yes
Yes

ELI
No
No
No
No

PHAP
Yes
Yes
Yes
Yes

162

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Attachment 3 – FMS Application Module

14.2

Match or Prematch Rank/Rating

Figure 15.2-a. Match or Prematch Rank/Rating Form Fields

Table 15.2a. Match or Prematch Rank/Rating Form Fields
Field Name
Do you informally accept the tentative
match with the assignment indicated
above?
Reason for match decline?
Do you informally accept the tentative
prematch with the assignment indicated
above?
Reason for pre-match decline?

Values

EIS
Yes

LLS
Yes

FLIGHT
Yes

EEP
Yes

SAF
No

PMR/F
Yes

PH-TIPP
No

PHIFP
Yes

PE
Yes

ELI
No

PHAP
Yes

Yes
Yes

Yes
No

No
No

Yes
Yes

No
No

Yes
Yes

No
No

Yes
Yes

Yes

1. Accept
2. Decline

163

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Attachment 3 – FMS Application Module

15.1

Selection Status Acceptance Form

Table 15. Selection Status Acceptance Form
Field Name
1. Do you want to continue with the
selection process?

Values
1. Accept
2. Decline

EIS
Yes

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

Yes

2. Reason for Decline (if decline was
selected in #1)
Contact Information Confirmation
You can view and update your contact
information in the EIS Fellowship
Application Portal under Applicant
Profile. We will be using this information
to contact you regarding application
status and match.

1. The email listed on my
profile form is accurate and
accessible for the next 6
months. (Yes)
2. The phone number(s) listed
on my profile form are

164

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Attachment 3 – FMS Application Module

3.Information about this year’s Prematch
sites was sent to you via
email.**Expressing interest in a Prematch
site does not guarantee a Prematch.**

accurate and accessible for
the next 6 months. (Yes)

4. Are you interested in Prematching?
(Yes/No)
Please rank your interest in the following
prematch sites. Be sure to review the
Prematch Position Description
information and book sent via email.
Dropdown for host sites withresponse
options (0=No Interest; 1=Low Interest;
2=Moderate Interest; 3=High Interest

16.1

EIS Conference Interview Time Selection Form

Table 15. EIS Conference Interview Time Selection Form
Field Name
Host site & Interview Time Slot

Values
[drop down]

EIS
Yes

LLS
No

FLIGHT
No

EEP
No

SAF
No

PMR/F
No

PH-TIPP
No

PHIFP
No

PE
No

ELI
No

PHAP
No

165

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Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Please select an interview time slot

[drop down]

Yes

166

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Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Appendix
I. Field Value Tables
Appendix of Field Value Tables

Application
Locations
6.2 Citizenship
Status

Values
1
See the U.S. Department of State website
for current list:
https://www.state.gov/j/ct/list/c14151.htm

Approved Country
List

6.2 Citizenship
Status

United States
Anguilla
Antigua
Australia
Bahamas
Barbados
Barbuda
Belize
Bermuda
British Virgin Islands
Canada
Dominica
Grand Cayman Islands

PHAP Subject
Areas

6.8.1 Special
Requirements

Adolescent & School Health (non-STI)
Community Health Improvement Planning (CHIP)/Community Health
Assessments (CHA)
Chronic Disease
Emergency/Disaster Preparedness and Response
Environmental Health
Genomics
Health Equity/Access to Care
Health Department Improvement/Accreditation
Immunizations/Vaccine Preventable Disease Investigation
Sexually Transmitted Disease Prevention
Tuberculosis Prevention
HIV Prevention
Viral Hepatitis Prevention
Adolescent/school-based Sexually Transmitted Disease prevention
Other Infectious Disease
Injury Prevention
Maternal & Infant Health
Public Health Policy & Law

Field Name
State Sponsor of
Terrorism Country
List

Values
2

Values
3

Values
4

Grenada
Guyana
Irish Republic
Jamaica
Montserrat
New Zealand
Saint Kitts and Nevis
St. Lucia
St. Vincent & the Grenadine
Tabago
Trinidad
Turks and Caicos Islands
United Kingdom

167

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Attachment 3 – FMS Application Module

Undergraduate
Degree List

7.7 Degree

Graduate Degree
List

7.7 Degree

Public Health Surveillance
Oral Health
AB
AM
BA
BS
BS/BA
BSc
DHS
DHSc
DNSc
DPH
DPhil
DrPH
DrS
DrSc
EdD
MA
Med
MHS
MHSc
MHSE
MN
MPH
MPhil
MPHTM
MPVM
MS
MSVPH
MSc
MScPH
MSPH
MTM&H
PhD
SB
ScB
ScD
ScM
SM
Other

AB
AM
BA
BS
BS/BA
BSc
DHS
DHSc
DNSc
DPH
DPhil
DrPH
DrS
DrSc
EdD
MA
Med
MHS
MHSc
MHSE

168

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Attachment 3 – FMS Application Module
MN
MPH
MPhil
MPHTM
MPVM
MS
MSVPH
MSc
MScPH
MSPH
MTM&H
PhD
SB
ScB
ScD
ScM
SM
Other

Major
Classification List

7.7 Degree

Biological, biomedical, or animal sciences
Business, management
Community health, public health
Decision or quantitative sciences
Economics (agricultural, applied, health)
Engineering, industrial engineering, operations research
Environmental, occupational sciences
Epidemiology
Global, international health
Health education
Informatics (public health, clinical, nursing)
Health services administration, health policy analysis
Health services research, quantitative policy analysis
Information technology, information science, computer science
Liberal arts, general studies, humanities, language, literature
Maternal and child health
Mathematical sciences, statistics, biostatistics
Physical or chemical sciences
Political science, law
Public administration, policy analysis
Social/behavior science (anthropology, social work, psychology)
Other

Honor List

7.7 Degree

Magna Cum Laude
Summa Cum Laude
Cum Laude
Valedictorian
Benedictorian
Salutatorian
Phi Beta Kappa

State/Territory
List

11.3 Location
Preferences
13.3.3 Location
Preferences

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Washington, DC
Florida
Georgia
Hawaii

Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island

169

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Attachment 3 – FMS Application Module

CDC Fellowship
List

11.4 CDC
Fellowship
Participation

Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
AACN Fellowship
AAMC Public Health Policy Fellowship
Applied Public Health Informatics Fellowship (APHIF)
APTR Preventive Medicine and Public Health Fellowship
ASA/NCHS Research Fellowship Program
ASM Program in Infectious Disease and Public Health Microbiology
ASPH Allan Rosenfield Global Health Fellowship Program
ASPPH Public Health Fellowship Program
Biochemical Markers Fellowship
Collegiate Leaders in Environmental Health (CLEH)
CSTE Applied Epidemiology Fellowship Program
Dental Public Health Residency
DHPE Health Equity Fellowship Program
DHPE Internship Program for Public Health Practice Emory Rollins Earn and
Learn (REAL) Program
E-learning Institute (ELI)
Environmental Health Traineeship and Fellowship Program
Epidemic Intelligence Service (EIS)
Epidemiology Elective Program (EEP)
Evaluation Fellowship
Federal Work-Study Program (FWS)
Field Epidemiology Training Program (FETP)
Future Leaders in Infections and Global Health Threats (FLIGHT)
Future Public Health Leaders Program (FPHLP)
HACU National Internship Program (HNIP)
Health Systems Integration Program
Hubert Global Health Fellowship
Informatics Training in Place Program (I-TIPP)
International Emerging Infectious Diseases (IEID) Laboratory Fellowship Program
Internships and Externships in Public Health Law
James A Ferguson Emerging Infectious Diseases Fellowship
Junior Commissioned Officer Student Training and Extern Program (JRCOSTEP)
Laboratory Animal Medicine Residency Program (LAMRP)
Laboratory Leadership Service (LLS)
Maternal Child Health Careers/Research Initiatives for Student Enhancement –
Undergraduate Program (MCHC/RISE-UP)
Medical Toxicologist Fellowship Program
Morehouse College Project IHMOTEP Program
National Center for Health Statistics (NCHS) Academy Health Policy Fellowship
National Center for Health Statistics (NCHS) Postdoctoral Research Program

South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Pacific Islands
U.S. Virgin Islands

170

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Attachment 3 – FMS Application Module

II. Lookup Tables
Appendix of Lookup Tables

Lookup Table Name
Fellowship Lookup

Phone Code Lookup

Application
Locations
3. eFMS System
Help Desk Ticket

5.4 Phone Number

Values
1

Values
2

Values
3

CDC E-learning Institute
Fellowship Program (ELI)
CDC Steven M. Teutsch
Prevention Effectiveness (PE)
Fellowship
Epidemic Intelligence Service (EIS)
Epidemiology Elective Program
(EEP)
Future Leaders in Infections and
Global Health Threats (FLIGHT)
Laboratory Leadership Service
(LLS)
Population Health Training in
Place Program (PH-TIPP)
Population Health Workforce
Initiative (PHWI)
Preventive Medicine Residency
and Fellowship (PMR/F)
Public Health Associate Program
(PHAP)
Public Health Informatics
Fellowship Program (PHIFP)
Science Ambassador Fellowship
(SAF)
United States (1)
Azores (351)
Afghanistan (93)
Albania (355)
Algeria (213)
Andorra (376)
Angola (244)
Anguilla (U.K.) (1)
Antigua and Barbuda (1)
Argentina (54)
Armenia (374)
Aruba (297)
Australia (61)
Austria (43)
Azerbaijan (994)
Bahamas, The (1)
Bahrain (973)
Bangladesh (880)
Barbados (1)
Belarus (375)
Belgium (32)
Belize (501)
Benin (229)
Bermuda (U.K.) (1)
Bhutan (975)

Congo, Democratic Republic
of the (243)
Congo, Republic of the (242)
Cambodia (855)
Cameroon (237)
Canada (1)
Cape Verde (238)
Cayman Islands (U.K.) (1)
Central African Republic
(236)
Chad (235)
Chile (56)
China (86)
Christmas Island (Australia)
(61)
Cocos (Keeling) Islands
(Australia) (61)
Colombia (57)
Comoros (269)
Cook Islands (New Zealand)
(682)
Costa Rica (506)
C?te d'Ivoire (225)
Croatia (385)
Cuba (53)

Estonia (372)
Ethiopia (251)
Falkland Islands (Malvinas)
(500)
Faroe Islands (Denmark)
(298)
Fiji (679)
Finland (358)
France (33)
French Guiana (France) (594)
French Polynesia (France)
(689)
Falkland Islands (U.K.) (500)
Guinea-Bissau (245)
Gabon (241)
Gambia, The (220)
Guyana (592)
Haiti (509)
Georgia (995)
Honduras (504)
Germany (49)
Hong Kong SAR (China) (852)
Ghana (233)
Hungary (36)
Gibraltar (U.K.) (350)

Values
4

Italy (39)
Jamaica (1)
Japan (81)
Libya (218)
Jordan (962)
Kazakhstan (7)
Liechtenstein (423)
Kenya (254)
Lithuania (370)
Luxembourg (352)
Kiribati (686)
Macau SAR (China) (853)
Korea, North (850)
Macedonia (389)
Korea, South (82)
Kuwait (965)
Madagascar (261)
Kyrgyzstan (996)
Malawi (265)
Kosovo (381)
Malaysia (60)
Laos (856)
Maldives (960)
Latvia (371)
Mali (223)

Values
5

Netherlands Antilles (599)
Moldova (373)
New Caledonia (France) (687)
Monaco (377)
New Zealand (64)
Mongolia (976)
Nicaragua (505)
Montserrat (U.K.) (1)
Niger (227)
Morocco (212)
Nigeria (234)
Mozambique (258)
Niue (New Zealand) (683)
Madeira Islands (Portugal)
(351)
Norfolk Island (Australia)
(672)
Montenegro (382)
Northern Mariana Islands
(U.S.) (670)
Namibia (264)
Norway (47)
Nauru (674)
Oman (968)
Nepal (977)

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Attachment 3 – FMS Application Module
Bolivia (591)
Bosnia and Herzegovina (387)
Botswana (267)
Brazil (55)
British Indian Ocean Territory
(U.K.) (246)
Brunei (673)
Bulgaria (359)
Burkina Faso (226)
Burundi (257)
British Virgin Islands (1)
Burma (Myanmar) (95)
Canary Islands (Spain) (34)

Cyprus (357)
Czech Republic (420)
Denmark (45)
Djibouti (253)
Dominica (1)
Dominican Republic (1)
Easter Island (Chile) (56)
Ecuador (593)
Egypt (20)
El Salvador (503)
Equatorial Guinea (240)
Eritrea (291)

Iceland (354)
Greece (30)
India (91)
Greenland (Denmark) (299)
Indonesia (62)
Grenada (1)
Iran (98)
Guadeloupe (590)
Iraq (964)
Guatemala (502)
Ireland (353)
Guinea (224)
Israel (972)

Lebanon (961)
Malta (356)
Lesotho (266)
Marshall Islands (692)
Liberia (231)
Martinique (France) (596)
Mauritania (222)
Mauritius (230)
Mayotte (France) (262)
Netherlands, The (31)
Mexico (52)
Micronesia, Federated States
of (691)

Pakistan (92)
Palau (680)
Panama (507)
Papua New Guinea (675)
Paraguay (595)
Peru (51)
Samoa (685)
Philippines (63)
San Marino (378)
Pitcairn Islands (U.K.) (0)
S?o Tom? and Pr?ncipe (239)
Poland (48)
Saudi Arabia (966)
Portugal (351)
Qatar (974)
Senegal (221)
Seychelles (248)
R?union (France) (262)
Romania (40)
Sierra Leone (232)
Russia (7)
Singapore (65)
Rwanda (250)
Slovakia (421)
Saint Kitts and Nevis (1)
Slovenia (386)
Saint Lucia (1)
Solomon Islands (677)
Saint Vincent and the
Grenadines (1)
Somalia (252)
South Africa (27)
Spain (34)
Sri Lanka (94)
Sudan (249)
Suriname (597)
Swaziland (268)
Sweden (46)
Tokelau (New Zealand) (690)
Switzerland (41)
Syria (963)
Tonga (676)
Saint Helena (U.K.) (290)
Trinidad and Tobago (1)
Saint Pierre and Miquelon
(France) (508)
Serbia (381)
Timor-Leste (East Timor)
(670)
Taiwan (886)
Tajikistan (992)
Tanzania (255)
Thailand (66)
Togo (228)
Tunisia (216)
Turkey (90)
Turkmenistan (993)
Turks and Caicos Islands
(U.K.) (1)
Tuvalu (688)
Uganda (256)
Venezuela (58)
Ukraine (380)

172

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OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Country Lookup

5.5 Mailing Address
6.2 Citizenship
Status
6.10.2 Program &
Organization
8.6 Position
Location
9.6 Institution
Details and Location

United States
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla (U.K.)
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Azores
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda (U.K.)
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
British Indian Ocean Territory
(U.K.)
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma (Myanmar)
Burundi
Cambodia
Cameroon
Canada

Canary Islands (Spain)
Cape Verde
Cayman Islands (U.K.)
Central African Republic
China
Chad
Christmas Island (Australia)
Chile
Cocos (Keeling) Islands
(Australia)
Colombia
Comoros
Congo, Democratic Republic
of the
Congo, Republic of the
Cook Islands (New Zealand)
Costa Rica
Cote d'Ivoire
Djibouti
Croatia
Cuba
Dominica
Cyprus
Dominican Republic
Czech Republic
Easter Island (Chile)
Denmark
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Finland
Falkland Islands (U.K.)
Faroe Islands (Denmark)
France
Fiji

French Guiana (France)
French Polynesia (France)
Gabon
Gambia, The
Georgia
Germany
Ghana
Gibraltar (U.K.)
Greece
Guinea
Greenland (Denmark)
Grenada
Guinea-Bissau
Guadeloupe
Guyana
Guatemala
Haiti
Honduras
Hong Kong SAR (China)
Hungary
Iceland
India
Indonesia
Iran
Jamaica
Iraq
Japan
Ireland
Jordan
Israel
Kazakhstan
Italy
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos

Liberia
Latvia
Libya
Lebanon
Liechtenstein
Lesotho
Lithuania
Luxembourg
Macau SAR (China)
Macedonia
Madagascar
Madeira Islands (Portugal)
Malawi
Malaysia
Martinique (France)
Maldives
Mauritania
Mali
Mauritius
Malta
Mayotte (France)
Marshall Islands
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat (U.K.)
Morocco
Mozambique
Netherlands Antilles
Namibia
Nauru
Netherlands, The
Nepal
New Caledonia (France)
New Zealand
Nicaragua
Niger
Nigeria
Niue (New Zealand)
Northfolk Island (Australia)
Northern Mariana Islands
(U.S.)
Panama
Norway
Papua New Guinea
Oman

United Arab Emirates (971)
Vietnam (84)
Western Sahara (212)
United Kingdom (44)
Yemen (967)
Uruguay (598)
Zambia (260)
Uzbekistan (998)
Zimbabwe (263)
Vanuatu (678)
Other (0)
Paraguay
Other
Peru
Pakistan
Philippines
Palau
Pitcairn Islands (U.K.)
Poland
Portugal
Qatar
Reunion (France)
Romania
Russia
Rwanda
Saint Lucia
Saint Helena (U.K.)
Saint Pierre and Miquelon
(France)
Saint Kitts and Nevis
Saint Vincent and the
Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Somalia
Sierra Leone
Singapore
South Africa
Slovakia
Spain
Slovenia
Sri Lanka
Solomon Islands
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Togo
Thailand
Timor-Leste (East Timor)
Tokelau (New Zealand)
Tonga
Trinidad and Tobago

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Attachment 3 – FMS Application Module

Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
(U.K.)
Tuvalu
Vanuatu
Uganda
Venezuela
Ukraine
Vietnam
United Arab Emirates
Western Sahara
United Kingdom
Yemen
Uruguay
Zambia
Uzbekistan
Zimbabwe

State/Territory Lookup

5.5 Mailing Address
6.8.1 Special
Requirements
6.10.2 Program &
Organization
7.9 License
8.6 Position
Location
9.6 Institution
Details and Location

Center/Division/Branch 6.9.2 FLIGHT –
Lookup
Current EIS Position
6.10.2 Program &
Organization

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Washington, DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska

Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Pacific Islands
U.S. Virgin Islands
Guam
Northern Mariana Islands

NIOSH / Office of the Director /
Administrative Svcs Branch
(Cincinnati)
NIOSH / Office of the Director /
Administrative Svcs Branch
(Morgantown)
NIOSH / Office of the Director /
Administrative Svcs Branch
(Spokane)
NIOSH / Office of the Director /
Administrative Svrcs Branch
(Pittsburgh)

NCHS / Division of Health
Interview Statistics / Data
Analysis & Quality Assurance
Branch
CSELS / Division of Scientific
Education and Professional
Development / Education
and Training Se...
NCHHSTP / Division of
Tuberculosis Elimination /
Data Management and
Statistics Branch
NIOSH / Pittsburgh Mining
Research Division / Electrical

NIOSH / Pittsburgh Mining
Research Division / Fires and
Explosions Branch
NCEZID / Division of
Foodborne, Waterborne and
Environmental Diseases /
Food Safety Office
NCEZID / Division of Global
Migration and Quarantine /
Geographic Medicine and
Health Promotion B...
NCHS / Office of Analysis &
Epidemiology / Health
Promotion Statistics Branch

Research and Evaluation
Branch
NCEH / Division of Laboratory
Science / Inorganic and
radiation analytical
toxicology branch
CSELS / Division of Laboratory
Systems / Laboratory Training
and Services Branch
NCEH / Division of
Environmental Health
Science and Practice / Lead
Poisoning Prevention and
Envi...

CPR / Division of Select
Agents and Toxins /
Operations Branch
NCEZID / Office of the
Director / Office of the
Director
NCEH / Division of Laboratory
Science / Organic analytical
toxicology branch
NCHS / Office of the Director
/ Office of the Director
NIOSH / Division of Applied
Research & Technology /

174

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
NCHS / Office of Analysis &
Epidemiology / Aging & Chronic
Disease Statistics Branch
NIOSH / Health Effects Laboratory
Division / Allergy & Clinical
Immunology Branch
NCHS / Division of Health Care
Statistics / Ambulatory and
Hospital Care Statistics Branch
NIOSH / Division of Safety
Research / Analysis & Field
Branch
NCHS / Division of Health &
Nutrition Examination Surveys /
Analysis Branch
NCHS / Office of Analysis &
Epidemiology / Analytic Studies
Branch
NCEZID / Division of Scientific
Resources / Animal Resources
Branch
NCCDPHP / Division for Heart
Disease and Stroke Prevention /
Applied Research and Evaluation
Branch
NCCDPHP / Division of Population
Health / Applied Research and
Translation Branch
CPR / Division of State and Local
Readiness / Applied Science and
Evaluation Branch
NCCDPHP / Division of
Reproductive Health / Applied
Sciences Branch
NCEZID / Division of Vector-Borne
Diseases / Arboviral Diseases
Branch
NCEZID / Division of
Preparedness and Emerging
Infections / Arctic Investigations
Program
NCCDPHP / Division of Population
Health / Arthritis, Epilepsy and
Well-Being Branch
NCIRD / Immunization Services
Division / Assessment Branch
NCEH / Division of Environmental
Health Science and Practice /
Asthma and Community Health
Branch
NCEZID / Division of Vector-Borne
Diseases / Bacterial Diseases
Branch
NCEZID / Division of High
Consequence Pathogens &
Pathology / Bacterial Special
Pathogens Branch
NCHHSTP / Division of HIV/AIDS
Prevention Surveillance &
Epidemiology / Behavioral And
Clinical S...
NIOSH / Division of Applied
Research & Technology /

& Mechanical Systems Safety
Branch
NCHS / Division of Health
Interview Statistics / Data
Production & Systems
Branch
CPR / Division of Emergency
Operations / Emergency and
Risk Communications Branch
NCEZID / Division of VectorBorne Diseases / Dengue
Branch
NCEH / Division of
Environmental Health
Science and Practice /
Emergency Management,
Radiation, a...
NCBDDD / Division of
Congenital and
Developmental Disorders /
Developmental Disabilities
Branch
NCEZID / Division of
Preparedness and Emerging
Infections / Emergency
Preparedness and Response
B...
NCBDDD / Division of Human
Development and Disability /
Disability and Health Branch
CGH / Division of Global
Health Protection /
Emergency Response and
Recovery Branch
NIOSH / Division of
Compensation Analysis &
Support / Division of
Compensation Analysis &
Support
NCEH / Division of
Laboratory Science /
Emergency response branch
NCCDPHP / Division of Oral
Health / Division of Oral
Health
ATSDR / Division of
Toxicology and Human
Health Sciences / Emergency
Response Program
NIOSH / Health Effects
Laboratory Division /
Engineering & Control
Branch
NIOSH / Division of Applied
Research & Technology /
Engineering & Physical
Hazards Branch
NCEZID / Division of
Foodborne, Waterborne and
Environmental Diseases /
Enteric Diseases Epidemio...
NCEZID / Division of
Foodborne, Waterborne and

ATSDR / Division of
Toxicology and Human
Health Sciences / Geospatial
Research, Analysis, and Ser...
CGH / Division of Global
Health Protection / Global
Non-communicable Disease
Branch
NCCDPHP / Office on
Smoking and Health / Global
Tobacco Control Branch
NCHHSTP / Division of
Sexually Transmitted Disease
Prevention / Health Services
Research and Eval...
CGH / Division of Global HIV
and TB / Global Tuberculosis
Branch
NCIPC / Division of
Unintentional Injury
Prevention / Health Systems
and Trauma Systems Branch
NIOSH / Pittsburgh Mining
Research Division / Ground
Control Branch
NCEH / Division of Emergency
and Environmental Health
Services / Healthy
Community Design Initiative
NIOSH / Division of
Surveillance, Hazard
Evaluations & Field Studies /
Hazard Evaluations & Techn...
NCEH / Division of Emergency
and Environmental Health
Services / Healthy Homes and
Lead Poisoning...
NIOSH / Health Effects
Laboratory Division / Health
Communication Research
Branch
NCBDDD / Division of Blood
Disorders / Hemostasis
Laboratory Branch
NCCDPHP / Office of the
Director / Health
Communication Science
Office
NCHHSTP / Office of the
Director / Health
Communication Science
Office
CGH / Division of Global HIV
and TB / HIV Care and
Treatment Branch
NCBDDD / Office of the
Director / Health
Communication Science
Office
NCHHSTP / Division of
HIV/AIDS Prevention
Surveillance & Epidemiology
/ HIV Incidence and Case Su...

CSELS / Division of Public
Health Information and
Dissemination / Library
Science Branch
CPR / Division of Strategic
National Stockpile / Logistics
Branch
CPR / Division of Emergency
Operations / Logistics
Support Branch
NCHS / Division of Health
Care Statistics / Long-Term
Care Statistics Branch
CGH / Division of Parasitic
Diseases and Malaria /
Malaria Branch
CGH / Division of Global HIV
and TB / Management and
Operations Branch
NIOSH / Office of the Director
/ Management Systems
Branch
CGH / Division of Global HIV
and TB / Maternal and Child
Health Branch
NCCDPHP / Division of
Reproductive Health /
Maternal and Infant Health
Branch
NCIRD / Division of Bacterial
Branch / Meningitis and
Vaccine Preventable Diseases
Branch
CGH / Division of Global HIV
and TB / Monitoring,
Evaluation, and Data Analysis
Branch
NIOSH / Office of the Director
/ Office of Extramural
Coordination & Special
Projects
NCHS / Division of Vital
Statistics / Mortality Statistics
Branch
NCEZID / Division of
Foodborne, Waterborne and
Environmental Diseases /
Mycotic Diseases Branch
NCEH / Office of the Director
/ Office of Financial,
Administrative, and
Information Services
NCEH / Division of Laboratory
Science / Newborn screening
and molecular biology branch
NCIRD / Office of the Director
/ Office of Health
Communication Science
NCCDPHP / Division of
Nutrition, Physical Activity, &
Obesity / Nutrition Branch

Organizational Science &
Human Factors Branch
NCEZID / Division of
Foodborne, Waterborne and
Environmental Diseases /
Outbreak Response and Pre...
CGH / Division of Global
Health Protection / Overseas
Business Operations Branch
CGH / Division of Global HIV
and TB / Overseas Strategy
and Management Branch
CGH / Division of Parasitic
Diseases and Malaria /
Parasitic Diseases Branch
CSELS / Division of Health
Informatics and Surveillance
Systems / Partnerships and
Evaluation Branch
NIOSH / Health Effects
Laboratory Division /
Pathology & Physiological
Research Branch
NCCDPHP / Division of
Nutrition, Physical Activity, &
Obesity / Physical Activity
and Health Branch
CPR / Division of Strategic
National Stockpile / Planning
and Analysis Branch
NCHS / Division of Health &
Nutrition Examination
Surveys / Planning Branch
CPR / Division of Emergency
Operations / Plans, Training,
Exercise and Evaluation
Branch
NCIPC / Division of Violence
Prevention / Prevention
Practice and Translation
Branch
NCBDDD / Office of the
Director / Policy, Planning,
and Evaluation Team
NCHHSTP / Division of
HIV/AIDS PreventionIntervention & Support /
Prevention Program Branch
NCIRD / Division of Viral
Diseases / Polio and
Picornavirus Laboratory
Branch
NCBDDD / Division of
Congenital and
Developmental Disorders /
Prevention Research and
Translation...
CGH / Global Immunization
Division / Polio Eradication
NCCDPHP / Division of
Population Health /
Population Health
Surveillance Branch

175

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Biomonitoring & Health
Assessment Branch
NIOSH / Health Effects Laboratory
Division / Biostatistics &
Epidemiology Branch
NCEZID / Division of Foodborne,
Waterborne and Environmental
Diseases / Biostatistics and
Informa...
NCEZID / Division of Scientific
Resources / Biotechnology Core
Facility Branch
NCBDDD / Division of Congenital
and Developmental Disorders /
Birth Defects Branch
NCHS / Office of Management &
Operations / Building Operations
& Services Staff
NCHS / Office of Management &
Operations / Business Logistics
Staff
NCCDPHP / Division of Cancer
Prevention and Control / Cancer
Surveillance Branch
NCHHSTP / Division of HIV/AIDS
Prevention-Intervention &
Support / Capacity Building
Branch
CPR / Division of State and Local
Readiness / Capacity Building
Branch
ATSDR / Division of Community
Health Investigations / Central
Branch
NIOSH / Division of Applied
Research & Technology /
Chemical Exposure & Monitoring
NCBDDD / Division of Human
Development and Disability /
Child Development and Disability
Branch
NCEZID / Division of High
Consequence Pathogens &
Pathology / Chronic Viral Diseases
Branch
NCHS / Classification & Public
Health Data Standards Staff /
Classification & Public Health
Data ...
NCEZID / Division of Healthcare
Quality Promotion / Clinical &
Environmental Microbiology
Branch
NCEH / Division of Laboratory
Science / Clinical chemistry
branch
NCHHSTP / Division of
Tuberculosis Elimination / Clinical
Research Branch
NCHS / Division of Research &
Methodology / Collaborating
Center for Questionnaire Design
& Evalu...

Environmental Diseases /
Enteric Diseases Laborato...
CGH / Division of Parasitic
Diseases and Malaria /
Entomology Branch
ATSDR / Division of
Toxicology and Human
Health Sciences /
Environmental Epidemiology
Branch
NCCDPHP / Division of
Population Health /
Epidemiology and
Surveillance Branch
NCEH / Division of
Emergency and
Environmental Health
Services / Environmental
Health Services Br...
ATSDR / Division of
Toxicology and Human
Health Sciences /
Environmental Health
Surveillance Branch
NCHHSTP / Division of Viral
Hepatitis / Epidemiology and
Surveillance Branch
ATSDR / Division of
Toxicology and Human
Health Sciences /
Environmental Medicine
Branch
NCHHSTP / Division of
HIV/AIDS Prevention
Surveillance & Epidemiology
/ Epidemiology Branch
NCEH / Division of
Emergency and
Environmental Health
Services / Environmental
Public Health Read...
NCCDPHP / Office on
Smoking and Health /
Epidemiology Branch
ATSDR / Division of
Toxicology and Human
Health Sciences /
Environmental Toxicology
Branch
NCEZID / Division of
Healthcare Quality
Promotion / Epidemiology
Research and Innovations
Branch
NCCDPHP / Division of
Cancer Prevention and
Control / Epidemiology and
Applied Research Branch
CSELS / Division of Scientific
Education and Professional
Development / Epidemiology
Workforce Br...

NIOSH / Pittsburgh Mining
Research Division / Health
Communication, Surveillance,
Research Suppor...
CGH / Division of Global HIV
and TB / HIV Prevention
Branch
NCCDPHP / Office on
Smoking and Health / Health
Communications Branch
NCIPC / Division of
Unintentional Injury
Prevention / Home,
Recreation, and
Transportation Branch
CGH / Division of Global HIV
and TB / Health Informatics,
Data Management, and
Statistics Branch
NIOSH / Pittsburgh Mining
Research Division / Human
Factors Branch
NCEZID / Division of Global
Migration and Quarantine /
Immigrant, Refugee, and
Migrant Health Branch
NCIRD / Immunization
Services Division /
Immunization Information
System Support Branch
NCEZID / Division of
Healthcare Quality
Promotion / Immunization
Safety Office
CGH / Global Immunization
Division / Immunization
System Branch
NCIRD / Influenza Division /
Immunology and
Pathogenesis Branch
NIOSH / Division of
Surveillance, Hazard
Evaluations & Field Studies /
Industrywide Studies Branch
NCHS / Office of Analysis &
Epidemiology / Infant, Child,
& Women?s Health Statistics
Branch
NCEZID / Division of High
Consequence Pathogens &
Pathology / Infectious
Diseases Pathology Branch
NCIRD / Office of the Director
/ Influenza Coordination Unit
CGH / Division of Global HIV
and TB / International
Laboratory Branch
NCHS / Division of Health &
Nutrition Examination
Surveys / Informatics Branch
CSELS / Division of Public
Health Information and

NCHHSTP / Office of the
Director / Office of Health
Equity
NCEH / Division of Laboratory
Science / Nutritional
biomarkers branch
NCIRD / Office of the Director
/ Office of Informatics
NCCDPHP / Division of
Nutrition, Physical Activity, &
Obesity / Obesity Prevention
and Control Br...
NCIRD / Office of the Director
/ Office of Laboratory Science
NIOSH / Office of the Director
/ Office of Administrative &
Management Svcs
NCIRD / Office of the Director
/ Office of Management and
Operations
NCEH / Office of the Director
/ Office of Communication
NCHHSTP / Office of the
Director / Office of
Management and Program
Support
NCIPC / Office of the Director
/ Office of Communication
NCHS / Office of Planning
Budget and Legislation /
Office of Planning Budget and
Legislation
NCIRD / Office of the Director
/ Office of Policy
NCIPC / Office of the Director
/ Office of Policy and
Partnerships
NCEH / Office of the Director
/ Office of Policy, Planning,
and Evaluation
NCIPC / Office of the Director
/ Office of Program
Management and Operations
NCHHSTP / Office of the
Director / Office of Program
Planning & Policy
Coordination
CSELS / Division of Public
Health Information and
Dissemination / Office of
Public Health Genomics
NCCDPHP / Office of the
Director / Office of Public
Health Practice
NCIRD / Office of the Director
/ Office of Science and
Integrated Programs
NCHHSTP / Office of the
Director / Office of the
Associate Director for
Laboratory Science

NCHHSTP / Division of
HIV/AIDS PreventionIntervention & Support /
Prevention Research Branch
CSELS / Division of Scientific
Education and Professional
Development / Population
Health Workfor...
NCEZID / Division of High
Consequence Pathogens &
Pathology / Prion & Public
Health Office
NCEZID / Division of High
Consequence Pathogens &
Pathology / Poxvirus and
Rabies Branch
NCHHSTP / Office of the
Director / Program and
Performance Improvement
Office
NCIPC / Division of Analysis,
Research, and Practice
Integration / Practice
Integration and Evalu...
CGH / Division of Global HIV
and TB / Program Budget and
Extramural Management
Branch
NCEZID / Division of
Healthcare Quality
Promotion / Prevention &
Response Branch
NCCDPHP / Division of
Nutrition, Physical Activity, &
Obesity / Program
Development and Evaluatio...
NCHHSTP / Division of Viral
Hepatitis / Prevention Branch
NCCDPHP / Division for Heart
Disease and Stroke
Prevention / Program
Development and Services
Branch
NCHHSTP / Division of
HIV/AIDS PreventionIntervention & Support /
Prevention Communications
Branch
NCHHSTP / Division of
Adolescent and School
Health / Program
Development and Services
Branch
NCHHSTP / Division of
HIV/AIDS PreventionIntervention & Support /
Program Evaluation Branch
NCCDPHP / Division of
Diabetes Translation /
Program Implementation
Branch
CPR / Division of Select
Agents and Toxins / Program

176

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
NCHS / Division of Research &
Methodology / Collaborating
Center for Statistical Research &
Surve...
NCIRD / Immunization Services
Division / Communication and
Education Branch
NCHHSTP / Division of
Tuberculosis Elimination /
Communications, Education, and
Behavioral Studie...
CSELS / Division of Public Health
Information and Dissemination /
Community Guide Branch
NCCDPHP / Division of Cancer
Prevention and Control /
Comprehensive Cancer Control
Branch
ATSDR / Division of Toxicology
and Human Health Sciences /
Computational Toxicology and
Methods D...
NIOSH / Education & Information
Division / Document
Development Branch
NIOSH / National Personal
Protective Technology Laboratory
/ Conformity Verification &
Standards ...
NCCDPHP / Division of Population
Health / Coordinated State
Support Branch
NIOSH / Pittsburgh Mining
Research Division / Dust,
Ventilation & Toxic Substances
Branch
CGH / Division of Global Health
Protection / Country Strategy and
Implementation Branch
ATSDR / Division of Community
Health Investigations / Eastern
Branch
NCHS / Division of Vital Statistics
/ Data Acquisition, Classification
& Evaluation Branch
CGH / Division of Global HIV and
TB / Economics and Health
Services Research Branch

NCIRD / Influenza Division /
Epidemiology and
Prevention Branch
CGH / Division of Global
Health Protection /
Epidemiology, Informatics,
Surveillance and Lab Branch
NCCDPHP / Division of
Diabetes Translation /
Epidemiology and Statistics
Branch
NIOSH / National Personal
Protective Technology
Laboratory / Evaluation &
Testing Branch
NCHHSTP / Division of
Sexually Transmitted Disease
Prevention / Epidemiology
and Statistics Branch
NIOSH / Health Effects
Laboratory Division /
Exposure Assessment Branch
NCCDPHP / Division for
Heart Disease and Stroke
Prevention / Epidemiology
and Surveillance Branch
NCHHSTP / Division of
Sexually Transmitted Disease
Prevention / Field Services
Branch
NCBDDD / Division of Blood
Disorders / Epidemiology
and Surveillance Branch
CPR / Division of State and
Local Readiness / Field
Services Branch
CGH / Division of Global HIV
and TB / Epidemiology and
Surveillance Branch
NCHHSTP / Division of
Tuberculosis Elimination /
Field Services Branch
NIOSH / Respiratory Health
Division / Field Studies
Branch
NCCDPHP / Division of
Reproductive Health / Field
Support Branch

Dissemination / Informatics
Innovation Unit
NCHHSTP / Division of
HIV/AIDS Prevention
Surveillance & Epidemiology
/ Laboratory Branch
NCHHSTP / Office of the
Director / Informatics Office
NCHHSTP / Division of
Tuberculosis Elimination /
Laboratory Branch
NCHS / Office of Information
Services / Information Design
& Publishing Staff
NCHHSTP / Division of Viral
Hepatitis / Laboratory Branch
NCHS / Office of Information
Services / Information
Dissemination Staff
NIOSH / Education &
Information Division /
Information Resources and
Dissemination Branch
CSELS / Division of Laboratory
Systems / Laboratory Practice
Standards Branch
NCEZID / Division of
Preparedness and Emerging
Infections / Laboratory
Preparedness and Response
...
CSELS / Division of Health
Informatics and Surveillance
Systems / Information
Systems Branch
NCHHSTP / Division of
Sexually Transmitted Disease
Prevention / Laboratory
Reference and Research...
NCHS / Division of Vital
Statistics / Information
Technology Branch
NCHS / Office of Information
Technology / Information
Technology Solutions &
Services Staff
CSELS / Division of Laboratory
Systems / Laboratory

NCHHSTP / Office of the
Director / Office of the
Associate Director for Science
NCIPC / Office of the Director
/ Office of the Associate
Director for Science
NCHS / Office of the Director
/ Office of the Director
NCHS / Division of Health &
Nutrition Examination
Surveys / Office of the
Director
NCHS / Division of Health
Care Statistics / Office of the
Director
CPR / Office of the Director /
Office of the Director
NCHS / Division of Health
Interview Statistics / Office of
the Director
NCEZID / Division of
Healthcare Quality
Promotion / Office of the
Director/International
Infectio...
NCCDPHP / Division of
Reproductive Health / Office
of the Director
NCCDPHP / Division of Cancer
Prevention and Control /
Office of the Director/Office
of Internatio...
NCHS / Division of Vital
Statistics / Office of the
Director
NCEZID / Office of the
Director / One Health Office
NCHS / Office of Analysis &
Epidemiology / Office of the
Director
CPR / Division of Emergency
Operations / Operations
Branch
CGH / Office of the Director /
Office of the Director
NCHS / Division of Health &
Nutrition Examination
Surveys / Operations Branch
CSELS / Office of the Director
/ Office of the Director

Management and Operations
Branch
NCIRD / Immunization
Services Division / Program
Operations Branch
NCCDPHP / Division of
Cancer Prevention and
Control / Program Services
Branch
CPR / Division of Select
Agents and Toxins / Program
Services Branch
CPR / Division of State and
Local Readiness / Program
Services Branch
NCCDPHP / Office of the
Director / Program Services
Branch
NCCDPHP / Office on
Smoking and Health /
Program Services Branch
NCHHSTP / Division of
Sexually Transmitted Disease
Prevention / Programs
Development and Quality ...
NIOSH / Division of Safety
Research / Protective
Technology Branch
NCIRD / Division of Viral
Diseases / Respiratory
Viruses Branch
NCHHSTP / Division of
HIV/AIDS Prevention
Surveillance & Epidemiology
/ Quantitative Sciences and...
NCEZID / Division of Global
Migration and Quarantine /
Quarantine and Border
Health Services Branch
CPR / Division of Strategic
National Stockpile / Response
Branch
NCHS / Division of Vital
Statistics / Reproductive
Statistics Branch
NCEZID / Division of VectorBorne Diseases / Rickettsial
Zoonoses Branch
NCIPC / Division of Violence
Prevention / Research and
Evaluation Branch
NIOSH / Education &
Information Division / Risk
Evaluation Branch
NCHHSTP / Division of
Adolescent and School
Health / Research Application
and Evaluation Branch
NCCDPHP / Division of
Population Health / School
Health Branch

177

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
NIOSH / National Personal
Protective Technology
Laboratory / Research Branch
NCHS / Division of Research
& Methodology / Research
Data Center
NCHHSTP / Division of
Adolescent and School
Health / School-Based
Surveillance Branch
NCBDDD / Office of the
Director / Resource
Management Office
NCBDDD / Office of the
Director / Science and Public
Health Team
NCIRD / Division of Bacterial
Branch / Respiratory Diseases
Branch
CGH / Division of Global HIV
and TB / Science Integrity
Branch
ATSDR / Division of
Community Health
Investigations / Science
Support Branch
NCEZID / Division of
Preparedness and Emerging
Infections / Scientific and
Program Services Branch
NCEZID / Division of Scientific
Resources / Scientific
Products and Support Branch
CSELS / Division of Public
Health Information and
Dissemination / Scientific
Publications Branch
NCHHSTP / Division of
Sexually Transmitted Disease
Prevention / Social and
Behavioral Research an...
CGH / Division of Global HIV
and TB / Special Initiatives
Branch
NCHS / Office of Analysis &
Epidemiology / Special
Projects Branch
NCIPC / Division of Violence
Prevention / Special Surveys
& Prevention Initiatives
Branch (proposed)
NCEZID / Division of Scientific
Resources / Specimen
Management Branch
NIOSH / Spokane Mining
Research Division / Spokane
Mining Research Division
NIOSH / Division of
Surveillance, Hazard
Evaluations & Field Studies /
Statistical Support Most E...
NCIPC / Division of Analysis,
Research, and Practice

178

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Integration / Statistics,
Programming, and E...
CGH / Global Immunization
Division / Strategic
Information and Workforce
Development Branch
NCHS / Division of Health
Interview Statistics / Survey
Planning & Special Surveys
Branch
CGH / Division of Global HIV
and TB / Strategy, Policy, and
Communication Branch
CSELS / Division of Health
Informatics and Surveillance
Systems / Surveillance and
Data Branch
NCHS / Division of Health
Care Statistics / Technical
Services Branch
NCHHSTP / Division of
Sexually Transmitted Disease
Prevention / Surveillance and
Data Management ...
NCEH / Division of Laboratory
Science / Tobacco and
volatiles branch
NIOSH / Health Effects
Laboratory Division /
Toxicology & Molecular
Biology Branch
NIOSH / Division of Safety
Research / Surveillance and
Field Investigations Branch
NIOSH / Education &
Information Division /
Training Research &
Evaluation Branch
NCEZID / Division of
Healthcare Quality
Promotion / Surveillance
Branch
NCCDPHP / Division of
Diabetes Translation /
Translation, Health Education
and Evaluation Branch
NIOSH / Division of
Surveillance, Hazard
Evaluations & Field Studies /
Surveillance Branch
NCEZID / Division of Global
Migration and Quarantine /
U.S. - Mexico Unit
NCIPC / Division of Violence
Prevention / Surveillance
Branch
NCIRD / Immunization
Services Division / Vaccine
Supply and Assurance Branch
NIOSH / Respiratory Health
Division / Surveillance Branch

179

Attachment 3 – FMS Application Module

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
NCIRD / Division of Viral
Diseases / Viral
Gastroenteritis Branch
NCHHSTP / Division of
Tuberculosis Elimination /
Surveillance, Epidemiology, &
Outbreak Investiga...
NCEZID / Division of High
Consequence Pathogens &
Pathology / Viral Special
Pathogens Branch
NCIRD / Division of Viral
Diseases / Viral Vaccine
Preventable Diseases Branch
NCIRD / Influenza Division /
Virology, Surveillance and
Diagnosis Branch
NCEH / Division of
Environmental Health
Science and Practice / Water,
Food, and Environmental
Hea...
NCEZID / Division of
Foodborne, Waterborne and
Environmental Diseases /
Waterborne Diseases Preve...
ATSDR / Division of
Community Health
Investigations / Western
Branch
NIOSH / Western States
Division / Western States
Division
NCCDPHP / Division of
Reproductive Health /
Women?s Health and Fertility
Branch
NCHS / Office of
Management & Operations /
Workforce & Career
Development Staff
CGH / Division of Global
Health Protection /
Workforce and Institute
Development Branch
NIOSH / Pittsburgh Mining
Research Division /
Workplace Health Branch
NIOSH / World Trade Center
Health Program / World
Trade Center Health Program
NCBDDD / Division of
Congenital and
Developmental Disorders /
Zika Transition Unit
CGH / Global Immunization
Division / Accelerated
Disease Control and Vaccine
Preventable Diseases...
NCCDPHP / Office on
Smoking and Health / Office
of the Director

180

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

College Lookup

7.5
College/University

Air University - Alabama
Alabama A&M University Alabama
Alabama State University Alabama
Athens State University Alabama
Auburn University - Alabama
Auburn University at
Montgomery - Alabama
Birmingham-Southern College Alabama
Concordia College-Selma Alabama
Faulkner University - Alabama
Huntingdon College - Alabama
Jacksonville State University Alabama
Judson College - Alabama
Miles College - Alabama
Oakwood College - Alabama
Samford University - Alabama
Southeastern Bible College Alabama
Southern Christian University Alabama
Spring Hill College - Alabama
Stillman College - Alabama
Talladega College - Alabama
Troy University (Dothan campus)
- Alabama
Troy University (main campus) Alabama
Troy University (Montgomery
campus) - Alabama
Tuskegee University - Alabama
United States Sports Academy Alabama
University of Alabama
(Birmingham) - Alabama
University of Alabama (Huntsville)
- Alabama
University of Alabama (main
campus) - Alabama
University of Mobile - Alabama
University of Montevallo Alabama
University of North Alabama Alabama
University of South Alabama Alabama
University of West Alabama Alabama
Alaska Bible College - Alaska
Alaska Pacific University - Alaska
Sheldon Jackson College - Alaska
University of Alaska, Anchorage Alaska
University of Alaska, Fairbanks Alaska
University of Alaska, Southeast
(Juneau) - Alaska

Lutheran School of Theology
at Chicago - Illinois
Northwestern University Illinois
McKendree College - Illinois
Olivet Nazarene University Illinois
McMurray College - Illinois
Principia College - Illinois
Quincy University - Illinois
Robert Morris College Illinois
Rockford College - Illinois
Roosevelt University - Illinois
Rush University - Illinois
Western Illinois University Illinois
Saint Anthony College of
Nursing - Illinois
Wheaton College - Illinois
School of the Art Institute of
Chicago - Illinois
Anderson University Indiana
Shimer College - Illinois
Ball State University - Indiana
Southern Illinois University Illinois
Bethel College - Indiana
Spertus Institute of Jewish
Studies - Illinois
Butler University - Indiana
St. Xavier University - Illinois
Calumet College of St.
Joseph - Indiana
The Chicago School of
Professional Psychology Illinois
Christian Theological
Seminary - Indiana
Trinity Christian College Illinois
College of Technology at
South Bend/Elkhart - Indiana
Trinity International
University - Illinois
Concordia Theological
Seminary-Fort Wayne Indiana
University of Chicago Illinois
DePauw University - Indiana
University of Illinois - Illinois
Earlham College - Indiana
University of St. Francis Illinois
Franklin College - Indiana
Goshen College - Indiana
Grace College - Indiana
Hanover College - Indiana
Holy Cross College - Indiana
Huntington University Indiana

Concordia College-St. Paul Minnesota
Bethany Lutheran College Minnesota
Crossroads College Minnesota
Bethel University & Seminary
- Minnesota
Crown College - Minnesota
Capella University Minnesota
Gustavus Adolphus College Minnesota
Carleton College - Minnesota
College of Saint Benedict Minnesota
Hamline University Minnesota
Luther Seminary - Minnesota
Macalester College Minnesota
Martin Luther College Minnesota
Metropolitan State University
- Minnesota
Minneapolis College of Art &
Design - Minnesota
Minnesota State University,
Mankato - Minnesota
Minnesota State University,
Moorhead - Minnesota
North Central University Minnesota
Northwestern College Minnesota
Oak Hills Christian College Minnesota
Walden University Minnesota
Pillsbury Baptist Bible College
- Minnesota
William Mitchell College of
Law - Minnesota
Saint John's University Minnesota
Winona State University Minnesota
Saint Mary's University of
Minnesota - Minnesota
Alcorn State University Mississippi
Saint Olaf College Minnesota
Belhaven College - Mississippi
Southwest Minnesota State
University - Minnesota
Blue Mountain College Mississippi
St. Cloud State University Minnesota
Delta State University Mississippi

Montreat College - North
Carolina
Mount Olive College - North
Carolina
North Carolina A&T State
University - North Carolina
North Carolina Central
University - North Carolina
North Carolina School of the
Arts - North Carolina
North Carolina State
University - North Carolina
University of North Carolina,
Chapel Hill - North Carolina
North Carolina Wesleyan
College - North Carolina
University of North Carolina,
Charlotte - North Carolina
Peace College - North
Carolina
University of North Carolina,
Greensboro - North Carolina
Pfeiffer University - North
Carolina
Piedmont Baptist College North Carolina
University of North Carolina,
Pembroke - North Carolina
University of North Carolina,
Wilmington - North Carolina
Queens University of
Charlotte - North Carolina
Wake Forest University North Carolina
Roanoke Bible College North Carolina
Warren Wilson College North Carolina
Salem College - North
Carolina
Western Carolina University North Carolina
Shaw University - North
Carolina
Wingate University - North
Carolina
St. Andrews Presbyterian
College - North Carolina
Winston-Salem State
University - North Carolina
St. Augustine's College North Carolina
Dickinson State University North Dakota
Jamestown College - North
Dakota
University of North Carolina,
Asheville - North Carolina
Mayville State University North Dakota
Minot State University North Dakota

Providence College - Rhode
Island
Coker College - South
Carolina
Rhode Island College - Rhode
Island
College of Charleston - South
Carolina
Rhode Island School of
Design - Rhode Island
Columbia College - South
Carolina
Columbia International
University - South Carolina
Roger Williams University Rhode Island
Converse College - South
Carolina
Salve Regina University Rhode Island
Erskine College - South
Carolina
University of Rhode Island Rhode Island
Francis Marion University South Carolina
Allen University - South
Carolina
Furman University - South
Carolina
Anderson College - South
Carolina
Johnson & Wales UniversityCharleston - South Carolina
Lander University - South
Carolina
Benedict College - South
Carolina
Limestone College - South
Carolina
Bob Jones University - South
Carolina
Medical University of South
Carolina - South Carolina
Charleston Southern
University - South Carolina
Morris College - South
Carolina
Newberry College - South
Carolina
North Greenville University South Carolina
Voorhees College - South
Carolina
Presbyterian College - South
Carolina
Winthrop University - South
Carolina
Sherman College of Straight
Chiropractic - South Carolina
Wofford College - South
Carolina

181

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
A.T. Still University of Health
Sciences - Arizona
American Indian College of the
Assemblies of God - Arizona
Arizona State University - Arizona
Arizona State University
Polytechnic Campus - Arizona
Arizona State University West Arizona
DeVry University-Phoenix Arizona
Embry-Riddle Aeronautical
University - Arizona
Grand Canyon University Arizona
Northcentral University - Arizona
Northern Arizona University Arizona
Prescott College - Arizona
Southwestern College - Arizona
Thunderbird, The Garvin School
of International Management Arizona
University of Arizona - Arizona
University of Phoenix - Arizona
Western International University
- Arizona
Arkansas Baptist College Arkansas
Arkansas State University,
Jonesboro - Arkansas
Arkansas Tech University Arkansas
Central Baptist College - Arkansas
Harding University - Arkansas
Henderson State University Arkansas
Hendrix College - Arkansas
John Brown University - Arkansas
Lyon College - Arkansas
Ouachita Baptist University Arkansas
Philander Smith College Arkansas
Southern Arkansas University Arkansas
University of Arkansas,
Fayetteville - Arkansas
University of Arkansas, Fort Smith
- Arkansas
University of Arkansas, Little Rock
- Arkansas
University of Arkansas, Medical
Sciences - Arkansas
University of Arkansas,
Monticello - Arkansas
University of Arkansas, Pine Bluff
- Arkansas
University of Central Arkansas Arkansas
University of the Ozarks Arkansas

Manchester College - Indiana
Indiana Institute of
Technology - Indiana
Indiana State University Indiana
Marian College - Indiana
Indiana University,
Bloomington - Indiana
Martin University - Indiana
Indiana University, East Indiana
Oakland City University Indiana
Indiana University, Kokomo Indiana
Purdue University - Indiana
Indiana University,
Northwest - Indiana
Purdue University Calumet Indiana
Indiana University, South
Bend - Indiana
Purdue University North
Central - Indiana
Indiana University, Southeast
- Indiana
Rose-Hulman Institute of
Technology - Indiana
Indiana University/Purdue
University at Columbus Indiana
Saint Joseph's College Indiana
Indiana University/Purdue
University at Fort Wayne Indiana
Saint Mary's College Indiana
Indiana University/Purdue
University at Indianapolis Indiana
Saint Mary-of-the-Woods
College - Indiana
Indiana Wesleyan University
- Indiana
School of Technology at
Anderson/Muncie - Indiana
School of Technology at
Columbus/Greensburg Indiana
School of Technology at
Indianapolis - Indiana
School of Technology at
Kokomo - Indiana
School of Technology at New
Albany - Indiana
School of Technology at
Richmond - Indiana
Taylor University - Indiana
Central College - Iowa
Tri-State University - Indiana
University of Evansville Indiana

University of Minnesota,
Crookston - Minnesota
Jackson State University Mississippi
University of Minnesota,
Duluth - Minnesota
Magnolia Bible College Mississippi
University of Minnesota,
Morris - Minnesota
Millsaps College - Mississippi
University of Minnesota,
Twin Cities - Minnesota
Mississippi College Mississippi
University of Saint Thomas Minnesota
Mississippi State University Mississippi
Mississippi University for
Women - Mississippi
Mississippi Valley State
University - Mississippi
Rust College - Mississippi
Tougaloo College - Mississippi
University of Mississippi Mississippi
University of Mississippi
Medical Center - Mississippi
University of Southern
Mississippi - Mississippi
William Carey College Mississippi
A.T. Still University of Health
Sciences - Missouri
Columbia College - Missouri
Avila College - Missouri
Baptist Bible College Missouri
Concordia Seminary-St. Louis
- Missouri
Calvary Bible College &
Theological Seminary Missouri
Culver-Stockton College Missouri
Central Bible College Missouri
DeVry University-Kansas City
- Missouri
Central Christian College of
the Bible - Missouri
Drury University - Missouri
Central Methodist University
- Missouri
Evangel University - Missouri
Central Missouri State
University - Missouri
Fontbonne University Missouri
Cleveland Chiropractic
College - Missouri

North Dakota State
University - North Dakota
Trinity Bible College - North
Dakota
University of Mary - North
Dakota
University of North Dakota North Dakota
Cincinnati Christian
University - Ohio
Valley City State University North Dakota
Cleveland Institute of Art Ohio
Air Force Institute of
Technology - Ohio
Cleveland Institute of Music Ohio
Antioch College - Ohio
Cleveland State University Ohio
Art Academy of Cincinnati Ohio
College of Mount St. Joseph Ohio
Ashland University - Ohio
Columbus College of Art &
Design - Ohio
Baldwin-Wallace College Ohio
David N. Myers University Ohio
Bluffton University - Ohio
Defiance College - Ohio
Bowling Green State
University - Ohio
Denison University - Ohio
Capital University - Ohio
Franciscan University of
Steubenville - Ohio
Case Western Reserve
University - Ohio
Franklin University - Ohio
Cedarville University - Ohio
Heidelberg College - Ohio
Central State University Ohio
Hiram College - Ohio
John Carroll University - Ohio
Kent State University - Ohio
Kenyon College - Ohio
Lake Erie College - Ohio
Ohio Northern University Ohio
Laura & Alvin Siegal College
of Judaic Studies - Ohio
Ohio State University,
Columbus - Ohio
Lourdes College - Ohio
Ohio State University, Lima Ohio
Malone College - Ohio

South Carolina State
University - South Carolina
Augustana College - South
Dakota
Southern Wesleyan
University - South Carolina
Black Hills State University South Dakota
Dakota State University South Dakota
The Citadel - South Carolina
Dakota Wesleyan University South Dakota
University of South Carolina,
Aiken - South Carolina
Mount Marty College - South
Dakota
University of South Carolina,
Beaufort - South Carolina
National American University
- South Dakota
University of South Carolina,
Columbia - South Carolina
Northern State University South Dakota
University of South Carolina,
Lancaster - South Carolina
Oglala Lakota College - South
Dakota
University of South Carolina,
Sumter - South Carolina
Presentation College - South
Dakota
University of South Carolina,
Union - South Carolina
Sinte Gleska University South Dakota
South Dakota School of
Mines & Technology - South
Dakota
University of South Carolina,
Upstate - South Carolina
South Dakota State
University - South Dakota
University of Sioux Falls South Dakota
Freed-Hardeman University Tennessee
University of South Dakota South Dakota
Aquinas College - Tennessee
Johnson Bible College Tennessee
Austin Peay State University Tennessee
King College - Tennessee
Baptist Memorial College of
Health Sciences - Tennessee
Knoxville College - Tennessee
Belmont University Tennessee
Lambuth University Tennessee

182

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Williams Baptist College Arkansas
Alliant International University California
American Jewish University California
Antioch University-Los Angeles California
Art Center College of Design California
Azusa Pacific University California
Bethany College - California
Bethesda Christian University California
Biola University - California
California Baptist University California
California College of the Arts California
California Institute of Integral
Studies - California
California Institute of Technology
- California
California Institute of the Arts California
California Lutheran University California
California Maritime Academy California
California Pacific University California
California Polytechnic State
University, San Luis Obispo California
California State Polytechnic
University, Pomona - California
California State University,
Bakersfield - California
California State University,
Channel Islands - California
California State University, Chico California
California State University,
Dominguez Hills - California
California State University, East
Bay - California
California State University, Fresno
- California
California State University,
Fullerton - California
California State University, Long
Beach - California
California State University, Los
Angeles - California
California State University,
Monterey Bay - California
California State University,
Northridge - California
California State University,
Sacramento - California
California State University, San
Bernardino - California

Clarke College - Iowa
University of Indianapolis Indiana
Coe College - Iowa
University of Notre Dame Indiana
University of Saint Francis Indiana
Cornell College - Iowa
University of Southern
Indiana - Indiana
Des Moines UniversityOsteopathic Medical Center Iowa
Valparaiso University Indiana
Divine Word College - Iowa
Wabash College - Indiana
Dordt College - Iowa
Allen College - Iowa
Drake University - Iowa
Ashford University - Iowa
Briar Cliff College - Iowa
Emmaus Bible College - Iowa
Buena Vista University - Iowa
Faith Baptist Bible College &
Theological Seminary - Iowa
Graceland College - Iowa
Grand View College - Iowa
Grinnell College - Iowa
Iowa State University - Iowa
Iowa Wesleyan College Iowa
Kaplan University - Iowa
Loras College - Iowa
Luther College - Iowa
Maharishi University of
Management - Iowa
Morningside College - Iowa
Mount Mercy College - Iowa
Northwestern College of
Iowa - Iowa
Wartburg College - Iowa
Simpson College - Iowa
William Penn University Iowa
St. Ambrose University Iowa
Baker University - Kansas
University of Dubuque - Iowa
University of Iowa - Iowa
Barclay College - Kansas
University of Northern Iowa Iowa
Benedictine College - Kansas
Upper Iowa University - Iowa
Bethany College - Kansas
Vennard College - Iowa
Bethel College - Kansas
Waldorf College - Iowa
Central Christian College Kansas

Forest Institute of
Professional Psychology Missouri
College of the Ozarks Missouri
Greenleaf University Missouri
Hannibal-Lagrange College Missouri
Harris-Stowe State University
- Missouri
Lincoln University - Missouri
Lindenwood University Missouri
Logan College of Chiropractic
- Missouri
Maryville University of St.
Louis - Missouri
Missouri Baptist College Missouri
Missouri Southern State
University - Missouri
Missouri State University Missouri
Missouri Valley College Missouri
Missouri Western State
University - Missouri
Northwest Missouri State
University - Missouri
Ozark Christian College Missouri
Park University - Missouri
Rockhurst University Missouri
Saint Louis University Missouri
University of Missouri,
Columbia - Missouri
Southeast Missouri State
University - Missouri
Southwest Baptist University
- Missouri
University of Missouri,
Kansas City - Missouri
St. Louis College of Pharmacy
- Missouri
University of Missouri, Rolla Missouri
Stephens College - Missouri
University of Missouri, St.
Louis - Missouri
Truman State University Missouri
Washington University in St.
Louis - Missouri
Webster University - Missouri
Westminster College Missouri
William Jewell College Missouri
William Woods University Missouri

Ohio State University,
Mansfield - Ohio
Marietta College - Ohio
Ohio State University, Marion
- Ohio
Miami University of Ohio Ohio
Ohio University - Ohio
Mount Union College - Ohio
Ohio Wesleyan University Ohio
Mount Vernon Nazarene
University - Ohio
Otterbein College - Ohio
Muskingum College - Ohio
Shawnee State University Ohio
Northeastern Ohio
Universities College of
Medicine - Ohio
The College of Wooster Ohio
Notre Dame College - Ohio
The University of Findlay Ohio
Oberlin College - Ohio
Tiffin University - Ohio
Union Institute & University Ohio
Ohio Christian University Ohio
University of Akron - Ohio
Ohio Dominican University Ohio
University of Cincinnati - Ohio
University of Dayton - Ohio
Cameron University Oklahoma
University of Northwestern
Ohio - Ohio
University of Rio Grande Ohio
East Central University Oklahoma
Langston University Oklahoma
University of Toledo - Ohio
Mid-America Christian
University - Oklahoma
University of Toledo Health
Science Campus - Ohio
Northeastern State
University, Broken Arrow
campus - Oklahoma
Urbana University - Ohio
Northeastern State
University, Muskogee
campus - Oklahoma
Ursuline College - Ohio
Northwestern Oklahoma
State University - Oklahoma
Oklahoma Baptist University Oklahoma

Bethel College - Tennessee
Lane College - Tennessee
Bryan College - Tennessee
Lee University - Tennessee
Carson-Newman College Tennessee
LeMoyne-Owen College Tennessee
Christian Brothers University
- Tennessee
Lincoln Memorial University Tennessee
Church of God Theological
Seminary - Tennessee
Lipscomb University Tennessee
Crichton College - Tennessee
Martin Methodist College Tennessee
Cumberland University Tennessee
Maryville College - Tennessee
East Tennessee State
University - Tennessee
Meharry Medical College Tennessee
Fisk University - Tennessee
Memphis College of Art Tennessee
Middle Tennessee State
University - Tennessee
Milligan College - Tennessee
Rhodes College - Tennessee
South College - Tennessee
Southern Adventist
University - Tennessee
Southern College - Tennessee
University of Tennessee,
Knoxville - Tennessee
Southern College of
Optometry - Tennessee
Tennessee State University Tennessee
University of Tennessee,
Martin - Tennessee
Tennessee Technological
University - Tennessee
University of Tennessee,
Memphis - Tennessee
Tennessee Temple University
- Tennessee
University of the South Tennessee
Tennessee Wesleyan College
- Tennessee
Vanderbilt University Tennessee
Trevecca Nazarene University
- Tennessee
Abilene Christian University Texas
Tusculum College Tennessee

183

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
California State University, San
Marcos - California
California State University,
Stanislaus - California
Chapman University - California
Charles R. Drew University of
Medicine & Science - California
Church Divinity School of the
Pacific - California
Claremont Graduate University California
Claremont McKenna College California
Cogswell Polytechnical College California
Concordia University-Irvine California
DeVry University-Long Beach California
DeVry University-Pomona California
Dominican School of Philosophy
& Theology - California
Dominican University of
California - California
Fielding Graduate Institute California
Franciscan School of Theology California
Fresno Pacific University California
Fuller Theological Seminary California
Golden Gate University California
Graduate Theological Union California
Harvey Mudd College - California
Holy Names University California
Hope International University California
Humboldt State University California
Humphreys College - California
Institute of Transpersonal
Psychology - California
Jesuit School of Theology at
Berkeley - California
John F. Kennedy University California
Keck Graduate Institute of
Applied Life Sciences - California
La Sierra University - California
Life Pacific College - California
Lincoln University - California
Loma Linda University - California
Loyola Marymount University California
Marymount College - California
Menlo College - California
Mills College - California

Emporia State University Kansas
Fort Hays State University Kansas
Friends University - Kansas
Haskell Indian Nations
University - Kansas
Kansas State University Kansas
Kansas Wesleyan University Kansas
Manhattan Christian College
- Kansas
McPherson College - Kansas
Mid-America Nazarene
College - Kansas
Newman University - Kansas
Ottawa University - Kansas
Pittsburg State University Kansas
Southwestern College Kansas
Sterling College - Kansas
Tabor College - Kansas
University of Kansas - Kansas
Asbury Theological Seminary
- Kentucky
University of Kansas Medical
Center - Kansas
University of Saint Mary Kansas
Bellarmine College Kentucky
Washburn University Kansas
Berea College - Kentucky
Wichita State University Kansas
Brescia University - Kentucky
Alice Lloyd College Kentucky
Campbellsville University Kentucky
Asbury College - Kentucky
Centre College - Kentucky
Clear Creek Baptist Bible
College - Kentucky
Eastern Kentucky University Kentucky
Georgetown College Kentucky
Kentucky Christian University
- Kentucky
Kentucky Mountain Bible
College - Kentucky
Kentucky State University Kentucky
Kentucky Wesleyan College Kentucky
Lexington Theological
Seminary - Kentucky
Lindsey Wilson College Kentucky

Carroll College - Montana
Montana State University,
Billings - Montana
Salish Kootenai College Montana
Montana State University,
Bozeman - Montana
Montana State University,
Northern - Montana
University of Great Falls Montana
University of Montana,
Missoula - Montana
Montana Tech - Montana
University of Montana,
Western - Montana
Rocky Mountain College Montana
Bellevue University Nebraska
Chadron State College Nebraska
Clarkson College - Nebraska
College of Saint Mary Nebraska
Concordia UniversityNebraska - Nebraska
Creighton University Nebraska
Dana College - Nebraska
Doane College - Nebraska
Nebraska Christian College Nebraska
Grace University - Nebraska
Hastings College - Nebraska
Midland Lutheran College Nebraska
Nebraska Methodist College Nebraska
Nebraska Wesleyan
University - Nebraska
Peru State College - Nebraska
Union College - Nebraska
University of Nebraska,
Kearney - Nebraska
University of Nebraska,
Lincoln - Nebraska
University of Nebraska,
Medical Center - Nebraska
University of Nebraska,
Omaha - Nebraska
Wayne State College Nebraska
York College - Nebraska
Chester College of New
England - New Hampshire
Great Basin College - Nevada
Sierra Nevada College Nevada
Colby-Sawyer College - New
Hampshire
University of Nevada Nevada

Walsh University - Ohio
Oklahoma Christian
University of Science & Arts Oklahoma
Wilberforce University - Ohio
Oklahoma City University Oklahoma
Wilmington College - Ohio
Oklahoma Panhandle State
University - Oklahoma
Wittenberg University - Ohio
Oklahoma State University,
Center for Health Sciences Oklahoma
Wright State University Ohio
Oklahoma State University,
Stillwater - Oklahoma
Xavier University - Ohio
Oklahoma State University,
Tulsa - Oklahoma
Youngstown State University
- Ohio
Oklahoma Wesleyan
University - Oklahoma
Bacone College - Oklahoma
Oral Roberts University Oklahoma
Phillips University (closed July
1998) - Oklahoma
Eastern Oregon University Oregon
Rogers State University Oklahoma
Eugene Bible College Oregon
Southeastern Oklahoma
State University - Oklahoma
George Fox University Oregon
Southern Nazarene
University - Oklahoma
Lewis & Clark College Oregon
Southwestern Oklahoma
State University - Oklahoma
Linfield College - Oregon
St. Gregory's University Oklahoma
Marylhurst University Oregon
University of Central
Oklahoma - Oklahoma
Mount Angel Seminary Oregon
Multnomah Bible College &
Seminary - Oregon
University of Oklahoma Oklahoma
National College of
Naturopathic Medicine Oregon

Ambassador University
(closed spring 1997) - Texas
Union University - Tennessee
University of Memphis Tennessee
Amberton University - Texas
University of Tennessee,
Chattanooga - Tennessee
Angelo State University Texas
Arlington Baptist College Texas
Art Institute of Dallas - Texas
Art Institute of Houston Texas
Austin College - Texas
Austin Graduate School of
Theology - Texas
Austin Presbyterian
Theological Seminary - Texas
Baptist Missionary
Association Theological
Seminary - Texas
Baylor College of Dentistry Texas
Baylor College of Medicine Texas
Baylor University - Texas
College of Saint Thomas
More - Texas
Concordia University-Texas Texas
Criswell College - Texas
Houston Baptist University Texas
Dallas Baptist University Texas
Dallas Christian College Texas
Howard Payne University Texas
Dallas Theological Seminary Texas
Huston-Tillotson University Texas
DeVry University-Dallas Texas
Jarvis Christian College Texas
East Texas Baptist University
- Texas
Lamar University - Texas
Episcopal Theological
Seminary of the Southwest Texas
LeTourneau University Texas
Hardin-Simmons University Texas
Lubbock Christian University Texas
Health Sciences Center Texas

184

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Monterey Institute of
International Studies - California
Mount St. Mary's College California
National Hispanic University California
National University - California
Naval Postgraduate School California
New College of California California
Notre Dame de Namur University
- California
Occidental College - California
Otis College of Art & Design California
Pacific Oaks College - California
Pacific Union College - California
Pacifica Graduate Institute California
Pardee RAND Graduate School California
Patten College - California
Pepperdine University - California
Pitzer College - California
Platt College - California
Point Loma Nazarene University California
Pomona College - California
Saint Mary's College of California
- California
Samuel Merritt College California
San Diego Christian College California
San Diego State University California
San Francisco State University California
San Jose State University California
Santa Clara University - California
Saybrook Graduate School &
Research Center - California
Scripps College - California
Simpson University - California
Soka University of America California
Sonoma State University California
Southern California Institute of
Architecture - California
Southwestern University School
of Law - California
Stanford University - California
The Master's College - California
The Master's Seminary California
Thomas Aquinas College California
University of California, Berkeley California

Mid-Continent College Kentucky
Midway College - Kentucky
Morehead State University Kentucky
Murray State University Kentucky
Northern Kentucky
University - Kentucky
Pikeville College - Kentucky
Southern Baptist Theological
Seminary - Kentucky
Spalding University Kentucky
University of the
Cumberlands - Kentucky
St. Catharine College Kentucky
Sullivan University Kentucky
Western Kentucky University
- Kentucky
Thomas More College Kentucky
Centenary College of
Louisiana - Louisiana
Transylvania University Kentucky
Dillard University - Louisiana
Union College - Kentucky
Grambling State University Louisiana
University of Kentucky Kentucky
Louisiana College - Louisiana
University of Louisville Kentucky
Louisiana State University,
Alexandria - Louisiana
Louisiana State University,
Baton Rouge - Louisiana
Louisiana State University,
Health Sciences Center Louisiana
Louisiana State University,
Shreveport - Louisiana
Louisiana Tech University Louisiana
Loyola University New
Orleans - Louisiana
McNeese State University Louisiana
New Orleans Baptist
Theological Seminary Louisiana
Nicholls State University Louisiana
Northwestern State
University of Louisiana Louisiana
Our Lady of Holy Cross
College - Louisiana

Daniel Webster College - New
Hampshire
Antioch New England - New
Hampshire
Dartmouth College - New
Hampshire
Franklin Pierce College - New
Hampshire
Franklin Pierce Law Center New Hampshire
Granite State College - New
Hampshire
Keene State College - New
Hampshire
New England College - New
Hampshire
Plymouth State College - New
Hampshire
Rivier College - New
Hampshire
Saint Anselm College - New
Hampshire
Southern New Hampshire
University - New Hampshire
The Thomas More College of
Liberal Arts - New Hampshire
University of New Hampshire
at Manchester - New
Hampshire
University of New Hampshire
- New Hampshire
Berkeley College - New Jersey
Bloomfield College - New
Jersey
Caldwell College - New Jersey
Centenary College - New
Jersey
College of Saint Elizabeth New Jersey
Drew University - New Jersey
Fairleigh Dickinson University
- New Jersey
Felician College - New Jersey
Georgian Court College - New
Jersey
Kean University - New Jersey
Princeton University - New
Jersey
Monmouth University - New
Jersey
Ramapo College - New Jersey
Montclair State University New Jersey
Richard Stockton College of
New Jersey - New Jersey
New Jersey City University New Jersey
Rider University - New Jersey
Rowan University - New
Jersey
New Jersey Institute of
Technology - New Jersey

University of Oklahoma
Health Sciences Center Oklahoma
Northwest Christian College Oregon
University of Science & Arts
of Oklahoma - Oklahoma
Oregon Graduate Institute of
Science & Technology Oregon
University of Tulsa Oklahoma
Oregon Health Sciences
University - Oregon
Art Institute of Portland Oregon
Oregon Institute of
Technology - Oregon
Concordia UniversityPortland - Oregon
Oregon State University Oregon
Corban College - Oregon
Pacific Northwest College of
Art - Oregon
Pacific University - Oregon
Portland State University Oregon
Reed College - Oregon
Baptist Bible College Pennsylvania
Southern Oregon University Oregon
University of Oregon Oregon
Bloomsburg University of
Pennsylvania - Pennsylvania
University of Portland Oregon
Bryn Athyn College of the
New Church - Pennsylvania
Warner Pacific College Oregon
Bryn Mawr College Pennsylvania
Western Oregon University Oregon
Bucknell University Pennsylvania
Western States Chiropractic
College - Oregon
Cabrini College Pennsylvania
Willamette University Oregon
California University of
Pennsylvania - Pennsylvania
Albright College Pennsylvania
Carlow College - Pennsylvania
Allegheny College Pennsylvania

McMurry University - Texas
Midwestern State University
- Texas
Northwood University - Texas
Oblate School of Theology Texas
Our Lady of the Lake
University - Texas
Parker College of Chiropractic
- Texas
Paul Quinn College - Texas
Prairie View A&M University Texas
Rice University - Texas
Sam Houston State University
- Texas
Schreiner University - Texas
South Texas College of Law Texas
Southern Methodist
University - Texas
Southwestern Adventist
University - Texas
Southwestern Assemblies of
God University - Texas
Texas A&M International
University - Texas
Southwestern Baptist
Theological Seminary - Texas
Texas A&M University,
College Station - Texas
Southwestern Christian
College - Texas
Texas A&M University,
Commerce - Texas
Southwestern University Texas
Texas A&M University,
Corpus Christi - Texas
St. Edward's University Texas
Texas A&M University,
Galveston - Texas
St. Mary's University of San
Antonio - Texas
Texas A&M University,
Health Science Center - Texas
Stephen F. Austin State
University - Texas
Texas A&M University,
Kingsville - Texas
Sul Ross State University Texas
Texas A&M University,
Texarkana - Texas
Tarleton State University Texas
Texas Chiropractic College Texas
Texas Christian University Texas
Texas College - Texas

185

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
University of California, Davis California
University of California, Hastings
College of the Law - California
University of California, Irvine California
University of California, Los
Angeles - California
University of California, Merced California
University of California, Riverside
- California
University of California, San Diego
- California
University of California, San
Francisco - California
University of California, Santa
Barbara - California
University of California, Santa
Cruz - California
University of La Verne - California
University of Northern California California
University of Redlands - California
University of San Diego California
University of San Francisco California
University of Southern California California
University of the Pacific California
Vanguard University of Southern
California - California
Western State University College
of Law - California
Western University of Health
Sciences - California
Westminster Seminary California
- California
Westmont College - California
Whittier College - California
William Howard Taft University California
William Jessup University California
Woodbury University - California
Adams State College - Colorado
Colorado Christian University Colorado
Colorado College - Colorado
Colorado School of Mines Colorado
Colorado State University Colorado
Colorado State University-Pueblo
- Colorado
Colorado Technical University Colorado
Fort Lewis College - Colorado
Jones International University Colorado
Mesa State College - Colorado

Our Lady of the Lake College
- Louisiana
Southeastern Louisiana
University - Louisiana
Southern University, Baton
Rouge - Louisiana
Southern University, New
Orleans - Louisiana
Tulane University - Louisiana
University of Louisiana,
Lafayette - Louisiana
Husson College - Maine
University of Louisiana,
Monroe - Louisiana
University of New Orleans Louisiana
Maine College of Art - Maine
Xavier University of
Louisiana - Louisiana
Maine Maritime Academy Maine
Bates College - Maine
St. Joseph's College - Maine
Bowdoin College - Maine
Thomas College - Maine
Colby College - Maine
Unity College - Maine
College of the Atlantic Maine
University of Maine, Augusta
- Maine
University of Maine,
Farmington - Maine
University of Maine, Fort
Kent - Maine
University of Maine, Machias
- Maine
University of Maine, Orono Maine
University of Maine, Presque
Isle - Maine
University of Maine, School
of Law - Maine
University of New England Maine
Baltimore Hebrew University
- Maryland
University of Southern
Maine - Maine
Baltimore International
College - Maryland
Bowie State University Maryland
Capitol College - Maryland
Chesapeake College Maryland
College of Notre Dame of
Maryland - Maryland
Columbia Union College Maryland
Coppin State University Maryland

Rutgers University, Camden New Jersey
Rutgers University, New
Brunswick/Piscataway - New
Jersey
Rutgers University, Newark New Jersey
Saint Peter's College - New
Jersey
Seton Hall University - New
Jersey
Stevens Institute of
Technology - New Jersey
The College of New Jersey New Jersey
Thomas Edison State College
- New Jersey
College of Santa Fe - New
Mexico
University of Medicine &
Dentistry of New Jersey New Jersey
College of the Southwest New Mexico
William Paterson University New Jersey
Eastern New Mexico
University - New Mexico
Institute of American Indian
Arts - New Mexico
New Mexico Highlands
University - New Mexico
New Mexico Institute of
Mining & Technology - New
Mexico
New Mexico State University
- New Mexico
Southwestern College - New
Mexico
St. John's College-Santa Fe New Mexico
University of New Mexico New Mexico
Western New Mexico
University - New Mexico
Adelphi University - New York
Albany College of Pharmacy New York
Albany Medical College - New
York
Alfred University - New York
Arnold & Marie Schwartz
College of Pharmacy & Health
Sciences - New York
Cazenovia College - New York
Bank Street College of
Education - New York
City College - New York
Bard College - New York
Clarkson University - New
York
Barnard College - New York
Colgate University - New York

Carnegie Mellon University Pennsylvania
Alvernia College Pennsylvania
Cedar Crest College Pennsylvania
American College Pennsylvania
Chatham College Pennsylvania
Arcadia University Pennsylvania
Chestnut Hill College Pennsylvania
Cheyney University Pennsylvania
Clarion University of
Pennsylvania - Pennsylvania
College Misericordia Pennsylvania
Curtis Institute of Music Pennsylvania
Delaware Valley College Pennsylvania
DeSales University Pennsylvania
Gratz College - Pennsylvania
Dickinson College Pennsylvania
Grove City College Pennsylvania
Dickinson School of Law Pennsylvania
Gwynedd Mercy College Pennsylvania
Drexel University Pennsylvania
Haverford College in
Pennsylvania - Pennsylvania
Duquesne University Pennsylvania
Holy Family University Pennsylvania
East Stroudsburg University
of Pennsylvania Pennsylvania
Immaculata College Pennsylvania
Eastern College Pennsylvania
Indiana University of
Pennsylvania - Pennsylvania
Edinboro University of
Pennsylvania - Pennsylvania
Juniata College Pennsylvania
Elizabethtown College Pennsylvania
Keystone College Pennsylvania
Kings College - Pennsylvania
Franklin & Marshall College Pennsylvania

Texas Lutheran University Texas
Texas Southern University Texas
Texas State University - Texas
Texas State University, San
Marcos - Texas
Texas Tech University - Texas
Texas Wesleyan University Texas
Texas Woman's University Texas
Trinity University - Texas
University of Dallas - Texas
University of Houston (main
campus) - Texas
University of Houston, Clear
Lake - Texas
University of Houston,
Downtown - Texas
University of Texas,
Brownsville - Texas
University of Houston,
Victoria - Texas
University of Mary HardinBaylor - Texas
University of Texas, Dallas Texas
University of North Texas Texas
University of Texas, El Paso Texas
University of North Texas,
Health Science Center at Ft.
Worth - Texas
University of Texas, Health
Center at Tyler - Texas
University of Saint Thomas Texas
University of Texas, Health
Science Center at Houston Texas
University of Texas, Arlington
- Texas
University of Texas, Health
Science Center at San
Antonio - Texas
University of Texas, Austin Texas
University of Texas, M.D.
Anderson Cancer Center Texas
University of Texas, Medical
Branch at Galveston - Texas
University of Texas, Pan
American - Texas
University of Texas, Permian
Basin - Texas
University of Texas, San
Antonio - Texas
University of Texas,
Southwestern Medical
Center at Dallas - Texas

186

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Metropolitan State College of
Denver - Colorado
Naropa Institute - Colorado
National Technological University
- Colorado
Nazarene Bible College - Colorado
Regis University - Colorado
Rocky Mountain College of Art &
Design - Colorado
United States Air Force Academy
- Colorado
University of Colorado, Boulder Colorado
University of Colorado, Colorado
Springs - Colorado
University of Colorado, Denver Colorado
University of Colorado, Health
Sciences Center - Colorado
Quinnipiac College - Connecticut
University of Denver - Colorado
University of Northern Colorado Colorado
Sacred Heart University Connecticut
Western State College - Colorado
Southern Connecticut State
University - Connecticut
Albertus Magnus College Connecticut
Central Connecticut State
University - Connecticut
St. Joseph College - Connecticut
Charter Oak State College Connecticut
Trinity College - Connecticut
Connecticut College - Connecticut
United States Coast Guard
Academy - Connecticut
Eastern Connecticut State
University - Connecticut
University of Bridgeport Connecticut
Fairfield University - Connecticut
University of Connecticut Connecticut
Holy Apostles College & Seminary
- Connecticut
University of Hartford Connecticut
Mitchell College - Connecticut
University of New Haven Connecticut
Post University - Connecticut
Wesleyan University Connecticut
Western Connecticut State
University - Connecticut
Yale University - Connecticut
Delaware State University Delaware
Goldey-Beacom College Delaware

Morgan State University Maryland
Frostburg State University Maryland
Mount Saint Mary's
University - Maryland
Goucher College - Maryland
National Labor College Maryland
Hood College - Maryland
Salisbury University Maryland
Soujourner-Douglass College
- Maryland
Johns Hopkins University Maryland
St. John's College-Annapolis Maryland
Loyola College - Maryland
St. Mary's College of
Maryland - Maryland
Maryland institute, College
of Art - Maryland
St. Mary's Seminary &
University - Maryland
McDaniel College - Maryland
Tai Sophia Institute Maryland
The Uniformed Services
University of the Health
Sciences - Maryland
Towson University Maryland
United States Naval
Academy - Maryland
University College Maryland
University of Baltimore Maryland
University of Maryland,
Baltimore - Maryland
University of Maryland,
Baltimore County - Maryland
University of Maryland,
College Park - Maryland
University of Maryland,
Eastern Shore - Maryland
Villa Julie College - Maryland
Washington Bible College Maryland
Bentley College Massachusetts
Washington College Maryland
Berklee College of Music Massachusetts
American International
College - Massachusetts
Boston College Massachusetts
Amherst College Massachusetts

Baruch College - New York
College at Brockport - New
York
Boricua College - New York
College at Buffalo (Buffalo
State College) - New York
Brooklyn College - New York
College at Cortland - New
York
Canisius College - New York
College at Fredonia - New
York
College at Geneseo - New
York
College at New Paltz - New
York
College at Old Westbury New York
College at Oneonta - New
York
College at Oswego - New
York
College at Plattsburgh - New
York
College at Potsdam - New
York
College at Purchase - New
York
College of Agriculture &
Technology at Cobleskill New York
College of Agriculture &
Technology at Morrisville
(Morrisville State College) New York
College of Environmental
Science & Forestry - New
York
College of Mount St. Vincent
- New York
College of New Rochelle New York
College of Optometry - New
York
College of Saint Rose - New
York
Cornell University - New York
College of Staten Island New York
Culinary Institute of America
- New York
College of Technology at
Alfred (Alfred State
University) - New York
D'Youville College - New York
College of Technology at
Canton - New York
Daemen College - New York
College of Technology at
Delhi - New York
Davis College - New York

Kutztown University of
Pennsylvania - Pennsylvania
Gannon University Pennsylvania
La Roche College Pennsylvania
Geneva College Pennsylvania
Lafayette College Pennsylvania
Gettysburg College Pennsylvania
Lancaster Bible College Pennsylvania
LaSalle University Pennsylvania
Lebanon Valley College Pennsylvania
Lehigh University Pennsylvania
Lincoln University Pennsylvania
Lock Haven University of
Pennsylvania - Pennsylvania
Peirce College - Pennsylvania
Lycoming College Pennsylvania
Pennsylvania College of
Optometry - Pennsylvania
Mansfield University of
Pennsylvania - Pennsylvania
Pennsylvania College of
Technology - Pennsylvania
Marywood University Pennsylvania
Pennsylvania State
University, Abington Pennsylvania
Mercyhurst College Pennsylvania
Pennsylvania State
University, Altoona Pennsylvania
Messiah College Pennsylvania
Pennsylvania State
University, Beaver Pennsylvania
Millersville University of
Pennsylvania - Pennsylvania
Pennsylvania State
University, Berks Pennsylvania
Moore College of Art &
Design - Pennsylvania
Pennsylvania State
University, Brandywine Pennsylvania
Moravian College Pennsylvania
Pennsylvania State
University, College of
Medicine - Pennsylvania

University of Texas, Tyler Texas
University of the Incarnate
Word - Texas
Wayland Baptist University Texas
West Texas A&M University Texas
Wiley College - Texas
Brigham Young University Utah
College of Eastern Utah Utah
Dixie State College - Utah
Southern Utah University Utah
University of Utah - Utah
Utah State University - Utah
Utah Valley State College Utah
Weber State University Utah
Western Governors
University - Utah
Westminster College - Utah
Bennington College Vermont
Burlington College - Vermont
Castleton State University Vermont
Vermont Technical College Vermont
Averett College - Virginia
Bluefield College - Virginia
Bridgewater College - Virginia
Christendom College Virginia
Christopher Newport
University - Virginia
College of William and Mary Virginia
DeVry University-Crystal City
- Virginia
Eastern Mennonite
University - Virginia
Eastern Virginia Medical
School - Virginia
ECPI College of Technology Virginia
Emory & Henry College Virginia
Ferrum College - Virginia
George Mason University Virginia
George Washington
University-Virginia Campus Virginia
Hampden-Sydney College Virginia
Hampton University - Virginia
Hollins University - Virginia
Institute for the Psychological
Sciences - Virginia

187

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
University of Delaware Delaware
Wesley College - Delaware
Wilmington College - Delaware
Barry University - Florida
Beacon College - Florida
Bethune-Cookman College Florida
Carlos Albizu University-Miami Florida
Florida Atlantic University Florida
Chipola College - Florida
Florida Christian College - Florida
Clearwater Christian College Florida
Florida College - Florida
DeVry University-Orlando Florida
Florida Gulf Coast University Florida
Eckerd College - Florida
Florida Hospital College of Health
Sciences - Florida
Edward Waters College - Florida
Embry-Riddle Aeronautical
University - Florida
Florida Institute of Technology Florida
Florida International University Florida
Flagler College - Florida
Florida Agricultural & Mechanical
University - Florida
Florida Memorial University Florida
Florida Metropolitan University Florida
Florida Southern College - Florida
Florida State University - Florida
Hobe Sound Bible College Florida
Hodges University - Florida
Jacksonville University - Florida
Jones College - Florida
Keiser University - Florida
Lynn University - Florida
Miami International University of
Art & Design - Florida
New College of Florida - Florida
Northwood University - Florida
Stetson University - Florida
Nova Southeastern University Florida
Palm Beach Atlantic University Florida
The Baptist College of Florida Florida
Trinity College of Florida - Florida
Ringling School of Art & Design Florida
Troy State University-Florida
Region - Florida

Boston Conservatory Massachusetts
Anna Maria College Massachusetts
Boston Graduate School of
Psychoanalysis Massachusetts
Assumption College Massachusetts
Boston University Massachusetts
Atlantic Union College Massachusetts
Brandeis University Massachusetts
Babson College Massachusetts
Bridgewater State College Massachusetts
Bay Path College Massachusetts
Becker College Massachusetts
Cambridge College Massachusetts
Benjamin Franklin Institute
of Technology Massachusetts
Clark University Massachusetts
College of the Holy Cross Massachusetts
Curry College Massachusetts
Eastern Nazarene College Massachusetts
Elms College - Massachusetts
Emerson College Massachusetts
Emmanuel College Massachusetts
Endicott College Massachusetts
Fitchburg State College Massachusetts
Framingham State College Massachusetts
Gordon College Massachusetts
Massachusetts Maritime
Academy - Massachusetts
Gordon-Conwell Theological
Seminary - Massachusetts
Massachusetts School of
Professional Psychology Massachusetts
Hampshire College Massachusetts
Merrimack College Massachusetts
Harvard University Massachusetts

College of Technology at
Farmingdale (Farmingdale
State University) - New York
Dominican College - New
York
Columbia University - New
York
Dowling College - New York
Concordia College-Bronxville
- New York
Downstate Medical Center New York
Elmira College - New York
Empire State College - New
York
Excelsior College - New York
Fashion Institute of
Technology - New York
Five Towns College - New
York
Fordham University - New
York
Graduate School & University
Center - New York
Hamilton College - New York
Hartwick College - New York
Hebrew Union College-Jewish
Institute of Religion - New
York
Hilbert College - New York
Hobart and William Smith
Colleges - New York
Lehman College - New York
Hofstra University - New York
Long Island University,
Brentwood Campus - New
York
Houghton College - New York
Hunter College - New York
Long Island University,
Brooklyn Campus - New York
Institute of Technology at
Utica/Rome - New York
Long Island University, C.W.
Post Campus - New York
Iona College - New York
Long Island University,
Rockland Graduate Campus New York
Ithaca College - New York
Long Island University,
Southampton Graduate
Campus - New York
John Jay College of Criminal
Justice - New York
Long Island University,
Westchester Graduate
Campus - New York
Keuka College - New York
Manhattan College - New
York
Laboratory Institute of
Merchandising - New York

Mount Aloysius College Pennsylvania
Pennsylvania State
University, DuBois Pennsylvania
Muhlenberg College Pennsylvania
Pennsylvania State
University, Great Valley Pennsylvania
Neumann College Pennsylvania
Pennsylvania State
University, Greater Allegheny
- Pennsylvania
Pennsylvania State
University, Harrisburg Pennsylvania
Pennsylvania State
University, Hazleton Pennsylvania
Pennsylvania State
University, Lehigh Valley Pennsylvania
Pennsylvania State
University, Mont Alto Pennsylvania
Pennsylvania State
University, New Kensington Pennsylvania
Saint Joseph's University Pennsylvania
Pennsylvania State
University, Schuylkill Pennsylvania
Pennsylvania State
University, Shenango Pennsylvania
Saint Vincent College Pennsylvania
Pennsylvania State
University, The Eberly
Campus - Pennsylvania
Seton Hill College Pennsylvania
Pennsylvania State
University, University Park Pennsylvania
Shippensburg University of
Pennsylvania - Pennsylvania
Pennsylvania State
University, Wilkes-Barre Pennsylvania
Slippery Rock University of
Pennsylvania - Pennsylvania
Pennsylvania State
University, Worthington
Scranton - Pennsylvania
Susquehanna University Pennsylvania
Pennsylvania State
University, York Pennsylvania

Institute of Textile
Technology - Virginia
James Madison University Virginia
Jefferson College of Health
Sciences - Virginia
Liberty University - Virginia
Longwood University Virginia
Lynchburg College - Virginia
Marine Corps University Virginia
Mary Baldwin College Virginia
Marymount University Virginia
Norfolk State University Virginia
Old Dominion University Virginia
Radford University - Virginia
Randolph College - Virginia
Randolph-Macon College Virginia
Regent University - Virginia
Roanoke College - Virginia
Saint Paul's College - Virginia
Shenandoah University Virginia
Sweet Briar College - Virginia
United States Marine Corps
University - Virginia
University of Mary
Washington - Virginia
University of Richmond Virginia
University of Virginia Virginia
University of Virginia's
College at Wise - Virginia
Virginia Commonwealth
University - Virginia
Champlain College - Vermont
Virginia Intermont College Virginia
College of St. Joseph Vermont
Goddard College - Vermont
Green Mountain College Vermont
Johnson State College Vermont
Lyndon State College Vermont
Marlboro College - Vermont
Middlebury College Vermont
Norwich University - Vermont
Saint Michael's College Vermont
School for International
Training - Vermont

188

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Rollins College - Florida
University of Central Florida Florida
Saint John Vianney College
Seminary - Florida
University of Florida - Florida
Saint Leo College - Florida
University of Miami - Florida
South Florida Bible College &
Theological Seminary - Florida
University of North Florida Florida
Southeastern University - Florida
University of South Florida Florida
St. Petersburg College - Florida
University of Tampa - Florida
St. Thomas University - Florida
University of West Florida Florida
Warner Southern College - Florida
Webber International University Florida
Agnes Scott College - Georgia
Albany State University - Georgia
American InterContinental
University - Georgia
Armstrong Atlantic State
University - Georgia
Art Institute of Atlanta - Georgia
Emmanuel College - Georgia
Atlanta Christian College Georgia
Emory University - Georgia
Augusta State University Georgia
Fort Valley State University Georgia
Augusta State University Georgia
Georgia College & State
University - Georgia
Bauder College - Georgia
Georgia Institute of Technology Georgia
Berry College - Georgia
Georgia Southern University Georgia
Brenau University - Georgia
Georgia Southwestern State
University - Georgia
Brewton-Parker College - Georgia
Georgia State University - Georgia
Interdenominational Theological
Center - Georgia
Clark Atlanta University - Georgia
Kennesaw State University Georgia
Clayton College & State
University - Georgia
LaGrange College - Georgia
Columbus State University Georgia

Mount Holyoke College Massachusetts
Hult International Business
School - Massachusetts
Mount Ida College Massachusetts
Lasell College Massachusetts
New England College of
Optometry - Massachusetts
Lesley College Massachusetts
New England Conservatory
of Music - Massachusetts
Massachuetts College of
Pharmacy & Health Sciences
- Massachusetts
Newbury College Massachusetts
Massachusetts College of Art
- Massachusetts
Nichols College Massachusetts
Massachusetts College of
Liberal Arts - Massachusetts
North Adams State College Massachusetts
Northeastern University Massachusetts
Massachusetts Institute of
Technology - Massachusetts
Pine Manor College Massachusetts
Regis College Massachusetts
Salem State College Massachusetts
Simmons College Massachusetts
Simon's Rock College Massachusetts
Smith College Massachusetts
Springfield College Massachusetts
Stonehill College Massachusetts
Suffolk University Massachusetts
Weston Jesuit School of
Theology - Massachusetts
Tufts University Massachusetts
Wheaton College Massachusetts
University of Massachusetts,
Amherst - Massachusetts
Wheelock College Massachusetts
University of Massachusetts,
Boston - Massachusetts
Williams College Massachusetts

Manhattan School of Music New York
Le Moyne College - New York
Manhattanville College - New
York
Marist College - New York
Maritime College at Ft.
Schuyler - New York
Marymount College - New
York
Marymount Manhattan
College - New York
Medaille College - New York
Medger Evers College - New
York
Mercy College - New York
Metropolitan College of New
York - New York
Molloy College - New York
Monroe College - New York
Pace University - New York
Mount Saint Mary College New York
Nazareth College - New York
Parsons School of Design New York
New School University - New
York
Paul Smith's College - New
York
Polytechnic University of
New York - New York
New York City College of
Technology - New York
Pratt Institute - New York
Queens College - New York
New York College of Podiatric
Medicine - New York
Rensselaer Polytechnic
Institute - New York
New York Institute of
Technology - New York
Roberts Wesleyan College New York
New York Medical College New York
Rochester Institute of
Technology - New York
New York University - New
York
Saint Francis College - New
York
Niagara University - New York
Sarah Lawrence College New York
Nyack College - New York
School of Visual Arts - New
York
Siena College - New York
Skidmore College - New York
St. Bonaventure University New York

Swarthmore College Pennsylvania
Philadelphia Biblical
University - Pennsylvania
Temple University Pennsylvania
The Behrend College, Erie Pennsylvania
Philadelphia University Pennsylvania
Point Park University Pennsylvania
Thiel College - Pennsylvania
Robert Morris College Pennsylvania
Thomas Jefferson University Pennsylvania
Rosemont College Pennsylvania
United States Army War
College - Pennsylvania
Saint Francis University Pennsylvania
University of Pennsylvania Pennsylvania
University of Pittsburgh
(main campus) - Pennsylvania
University of Pittsburgh,
Bradford - Pennsylvania
University of Pittsburgh,
Greensburg - Pennsylvania
Widener University Pennsylvania
University of Pittsburgh,
Johnstown - Pennsylvania
Wilkes University Pennsylvania
University of Pittsburgh,
Titusville - Pennsylvania
Wilson College - Pennsylvania
University of Scranton Pennsylvania
York College of Pennsylvania
- Pennsylvania
University of the Arts Pennsylvania
American University of
Puerto Rico - Puerto Rico
University of the Sciences in
Philadelphia - Pennsylvania
Antillean Adventist University
- Puerto Rico
University Park (main
campus) - Pennsylvania
Caribbean University - Puerto
Rico
Ursinus College Pennsylvania
Carlos Albizu University, San
Juan - Puerto Rico
Valley Forge Christian College
- Pennsylvania

Virginia Military Institute Virginia
Southern Vermont College Vermont
Virginia Polytechnic Institute
and State University - Virginia
Sterling College - Vermont
Virginia State University Virginia
University of Vermont Vermont
Virginia Union University Virginia
Vermont Law School Vermont
Virginia Wesleyan College Virginia
Washington & Lee University
- Virginia
Washington Bible
College/Capital Bible
Seminary - Virginia
Antioch University-Seattle Washington
Art Institute of Seattle Washington
Bastyr University Washington
Central Washington
University - Washington
City University - Washington
Heritage University Washington
Eastern Washington
University - Washington
Northwest University Washington
Evergreen State College Washington
Pacific Lutheran University Washington
Gonzaga University Washington
Seattle Pacific University Washington
Seattle University Washington
St. Martin's College Washington
Trinity Lutheran College Washington
University of Puget Sound Washington
University of Washington
(Bothell campus) Washington
University of Washington
(Seattle/Main campus) Washington
University of Washington
(Tacoma campus) Washington

189

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Life University - Georgia
Covenant College - Georgia
Macon State College - Georgia
Dalton State College - Georgia
Medical College of Georgia Georgia
Mercer University - Georgia
Morehouse College - Georgia
Morehouse School of Medicine Georgia
North Georgia College & State
University - Georgia
Toccoa Falls College - Georgia
Oglethorpe University - Georgia
Truett-McConnell College Georgia
Paine College - Georgia
University of Devry-Georgia Georgia
Piedmont College - Georgia
Reinhardt College - Georgia
University of Georgia - Georgia
Savannah College of Art & Design
- Georgia
Valdosta State University Georgia
Savannah State University Georgia
Wesleyan College - Georgia
Shorter College - Georgia
University of Guam - Guam
South University - Georgia
Brigham Young University-Hawaii
- Hawaii
Southern Polytechnic State
University - Georgia
Chaminade University - Hawaii
Spelman College - Georgia
Hawaii Pacific University - Hawaii
State University of West Georgia Georgia
University of Hawaii, Hilo - Hawaii
Thomas University - Georgia
University of Hawaii, Manoa Hawaii
University of Hawaii, West Oahu Hawaii
Albertson College of Idaho - Idaho
Boise State University - Idaho
Brigham Young University-Idaho Idaho
Idaho State University - Idaho
Lewis-Clark State College - Idaho
Columbia College - Illinois
Northwest Nazarene College Idaho
University of Idaho - Idaho
Concordia University-Chicago Illinois
Adler School of Professional
Psychology - Illinois
DePaul University - Illinois

University of Massachusetts,
Dartmouth - Massachusetts
Worcester Polytechnic
Institute - Massachusetts
University of Massachusetts,
Lowell - Massachusetts
Worcester State College Massachusetts
University of Massachusetts,
Medical School at Worcester
- Massachusetts
Adrian College - Michigan
Wellesley College Massachusetts
Albion College - Michigan
Wentworth Institute of
Technology - Massachusetts
Alma College - Michigan
Western New England
College - Massachusetts
Andrews University Michigan
Westfield State College Massachusetts
Aquinas College - Michigan
Baker College - Michigan
Calvin College - Michigan
Central Michigan University Michigan
Cleary University - Michigan
College for Creative Studies Michigan
Concordia College-Ann Arbor
- Michigan
Cornerstone University Michigan
Cranbrook Academy of Art Michigan
Davenport University Michigan
Kuyper College - Michigan
Eastern Michigan University Michigan
Lake Superior State
University - Michigan
Ferris State University Michigan
Lawrence Technological
University - Michigan
Finlandia University Michigan
Madonna University Michigan
Grace Bible College Michigan
Marygrove College Michigan
Grand Valley State University
- Michigan
Michigan State University Michigan
Hillsdale College - Michigan

St. John Fisher College - New
York
St. John's University - New
York
St. Joseph's College - New
York
The Sage Colleges - New York
St. Lawrence University - New
York
Touro College - New York
St. Thomas Aquinas College New York
Unification Theological
Seminary - New York
State University of New York,
Albany - New York
Union College - New York
State University of New York,
Binghamton - New York
Union Theological Seminary New York
State University of New York,
Buffalo - New York
United States Merchant
Marine Academy - New York
State University of New York,
Stony Brook - New York
United States Military
Academy - New York
Syracuse University - New
York
University of Rochester - New
York
Teachers College, Columbia
University - New York
Upstate Medical University New York
The Cooper Union for the
Advancement of Science &
Art - New York
Utica College of Syracuse
University - New York
The Jewish Theological
Seminary of America - New
York
Vassar College - New York
The Juilliard School - New
York
Vaughn College of
Aeronautics & Technology New York
The Rockefeller University New York
Wagner College - New York
Webb Institute - New York
Wells College - New York
Yeshiva University - New York
York College - New York
Appalachian State University
- North Carolina
Barton College - North
Carolina

Centro de Estudios
Avanzados de Puerto Rico y
el Caribe - Puerto Rico
Villanova University Pennsylvania
Conservatorio de Musica de
Puerto Rico - Puerto Rico
Washington & Jefferson
College - Pennsylvania
Escuela de Artes Plasticas de
Puerto Rico - Puerto Rico
Waynesburg College Pennsylvania
Polytechnic University of
Puerto Rico - Puerto Rico
West Chester University of
Pennsylvania - Pennsylvania
Ponce School of Medicine Puerto Rico
Westminster College Pennsylvania
Pontificia Universidad
Catolica de Puerto Rico Puerto Rico
Westminster Theological
Seminary - Pennsylvania
Seminario Evangelico de
Puerto Rico - Puerto Rico
Sistema Universitario Ana G.
Mendez - Puerto Rico
Universidad Central de
Bayamon - Puerto Rico
Universidad Central del
Caribe - Puerto Rico
Universidad Interamericana
de Puerto Rico, School of Law
- Puerto Rico
Universidad del Este - Puerto
Rico
Universidad del Sagrado
Corazon - Puerto Rico
Universidad Interamericana
de Puerto Rico, School of
Optometry - Puerto Rico
Universidad del Turabo Puerto Rico
Universidad Metropolitana Puerto Rico
Universidad Interamericana
de Puerto Rico (Aguadilla
Campus) - Puerto Rico
University of Puerto Rico,
Aguadilla - Puerto Rico
Universidad Interamericana
de Puerto Rico (Arecibo
Campus) - Puerto Rico
University of Puerto Rico,
Arecibo - Puerto Rico
University of Puerto Rico,
Bayamon - Puerto Rico
Universidad Interamericana
de Puerto Rico (Barranquitas
Campus) - Puerto Rico

Walla Walla University Washington
Western Washington
University - Washington
Washington State University
(Spokane campus) Washington
Whitman College Washington
Washington State University
(Tri-Cities campus) Washington
Whitworth College Washington
Washington State University
(Vancouver campus) Washington
American University Washington, DC
Corcoran College of Art &
Design - Washington, DC
Gallaudet University Washington, DC
George Washington
University (Main
campus/Foggy Bottom) Washington, DC
George Washington
University (Mount Vernon
campus) - Washington, DC
George Washington
University (Virginia Campus) Washington, DC
Georgetown University Washington, DC
Howard University Washington, DC
Strayer University Washington, DC
Institute of World Politics Washington, DC
Joint Military Intelligence
College - Washington, DC
The Catholic University of
America - Washington, DC
National Defense University Washington, DC
Trinity University Washington, DC
Southeastern University Washington, DC
University of the District of
Columbia - Washington, DC
Washington Theological
Union - Washington, DC
Wesley Theological Seminary
- Washington, DC
Alderson-Broaddus College West Virginia
Bethany College - West
Virginia
Bluefield State College - West
Virginia

190

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
American College of Education Illinois
DeVry University - Illinois
Argosy University - Illinois
DeVry University-Chicago - Illinois
Augustana College - Illinois
DeVry University-DuPage - Illinois
Aurora University - Illinois
Dominican University - Illinois
Benedictine University - Illinois
East-West University - Illinois
Blackburn College - Illinois
Eastern Illinois University - Illinois
Bradley University - Illinois
Elmhurst College - Illinois
Chicago State University - Illinois
Erikson Institute - Illinois
College of DuPage - Illinois
Eureka College - Illinois
Governors State University Illinois
Greenville College - Illinois
Illinois College - Illinois
Illinois Institute of Technology Illinois
Illinois State University - Illinois
Illinois Wesleyan University Illinois
Midwestern University - Illinois
Judson College - Illinois
Millikin University - Illinois
Kendall College - Illinois
Monmouth College - Illinois
Knox College - Illinois
Moody Bible Institute - Illinois
Lake Forest College - Illinois
National University of Health
Sciences - Illinois
Lake Forest Graduate School of
Management - Illinois
National-Louis University - Illinois
Lakeview College of Nursing Illinois
North Central College - Illinois
Lewis University - Illinois
North Park University - Illinois
Lincoln Christian College &
Seminary - Illinois
Northeastern Illinois University Illinois
Loyola University Chicago - Illinois
Northern Illinois University Illinois

Michigan Technological
University - Michigan
Hope College - Michigan
Northern Michigan
University - Michigan
Kalamazoo College Michigan
Northwood University Michigan
Kendall College of Art &
Design - Michigan
Oakland University Michigan
Kettering University Michigan
Olivet College - Michigan
Rochester College - Michigan
Saginaw Valley State
University - Michigan
Siena Heights University Michigan
Spring Arbor University Michigan
University of Detroit Mercy Michigan
University of Michigan, Ann
Arbor - Michigan
University of Michigan,
Dearborn - Michigan
University of Michigan, Flint Michigan
Walsh College - Michigan
Wayne State University Michigan
College of St. Catherine Minnesota
Western Michigan University
- Michigan
College of St. Scholastica Minnesota
Alfred Adler Institute Minnesota
College of Visual Arts Minnesota
Augsburg College Minnesota
Concordia CollegeMoorhead - Minnesota
Bemidji State University Minnesota

Belmont Abbey College North Carolina
Fayetteville State University North Carolina
Bennett College - North
Carolina
Gardner-Webb University North Carolina
Brevard College - North
Carolina
Greensboro College - North
Carolina
Campbell University - North
Carolina
Guilford College - North
Carolina
Catawba College - North
Carolina
High Point University - North
Carolina
Chowan College - North
Carolina
Johnson C. Smith University North Carolina
Davidson College - North
Carolina
Lees-McRae College - North
Carolina
Duke University - North
Carolina
Lenoir-Rhyne College - North
Carolina
East Carolina University North Carolina
Livingstone College - North
Carolina
Elizabeth City State
University - North Carolina
Louisburg College - North
Carolina
Elon University - North
Carolina
Mars Hill College - North
Carolina
Meredith College - North
Carolina
Methodist College - North
Carolina

University of Puerto Rico,
Carolina - Puerto Rico
Universidad Interamericana
de Puerto Rico (Bayamon
Campus) - Puerto Rico
University of Puerto Rico,
Cayey - Puerto Rico
Universidad Interamericana
de Puerto Rico (Fajardo
Campus) - Puerto Rico
University of Puerto Rico,
Ciencias Medicas - Puerto
Rico
Universidad Interamericana
de Puerto Rico (Guayama
Campus) - Puerto Rico
University of Puerto Rico,
Humacao - Puerto Rico
Universidad Interamericana
de Puerto Rico (Metropolitan
Campus) - Puerto Rico
University of Puerto Rico,
Mayaguez - Puerto Rico
Universidad Interamericana
de Puerto Rico (Ponce
Campus) - Puerto Rico
University of Puerto Rico,
Ponce - Puerto Rico
Universidad Interamericana
de Puerto Rico (San German
Campus) - Puerto Rico
University of Puerto Rico, Rio
Piedras - Puerto Rico
University of Puerto Rico,
Utuado - Puerto Rico
Brown University - Rhode
Island
Bryant College - Rhode Island
Johnson & Wales University Rhode Island
Claflin University - South
Carolina
Naval War College - Rhode
Island
Clemson University - South
Carolina
New England Institute of
Technology - Rhode Island
Coastal Carolina University South Carolina

Concord University - West
Virginia
Davis & Elkins College - West
Virginia
Fairmont State College West Virginia
Ohio Valley College - West
Virginia
Glenville State College - West
Virginia
Marshall University - West
Virginia
Salem International
University - West Virginia
Mountain State University West Virginia
Shepherd University - West
Virginia
University of Charleston West Virginia
West Liberty State College West Virginia
West Virginia State University
- West Virginia
West Virginia University West Virginia
West Virginia University at
Parkersburg - West Virginia
West Virginia University
Institute of Technology West Virginia
West Virginia Wesleyan
College - West Virginia
Wheeling Jesuit University West Virginia
Alverno College - Wisconsin
Beloit College - Wisconsin
Cardinal Stritch College Wisconsin
Carthage College - Wisconsin
Carroll College - Wisconsin
Concordia UniversityWisconsin - Wisconsin
Edgewood College Wisconsin
Herzing College - Wisconsin
Lakeland College - Wisconsin
Lawrence University Wisconsin
Maranatha Baptist Bible
College - Wisconsin
Marian College of Fond du
Lac - Wisconsin
Marquette University Wisconsin
St. Norbert College Wisconsin
Medical College of Wisconsin
- Wisconsin
University of Wisconsin, Eau
Claire - Wisconsin
Milwaukee School of
Engineering - Wisconsin

191

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

University of Wisconsin,
Green Bay - Wisconsin
Mount Mary College Wisconsin
University of Wisconsin,
LaCrosse - Wisconsin
Northland College Wisconsin
University of Wisconsin,
Madison - Wisconsin
Ripon College - Wisconsin
University of Wisconsin,
Milwaukee - Wisconsin
Silver Lake College Wisconsin
University of Wisconsin,
Oshkosh - Wisconsin
University of Wisconsin,
Parkside - Wisconsin
University of Wisconsin,
Platteville - Wisconsin
University of Wisconsin, River
Falls - Wisconsin
University of Wisconsin,
Stevens Point - Wisconsin
University of Wisconsin,
Stout - Wisconsin
University of Wisconsin,
Superior - Wisconsin
University of Wisconsin,
Whitewater - Wisconsin
Wisconsin Lutheran College Wisconsin
Viterbo University Wisconsin
Wisconsin School of
Professional Psychology Wisconsin
University of Wyoming Wyoming
Other: Rocky Vista University
College of Osteopathic
Medicine - Colorado
Lake Erie College of
Osteopathic Medicine
(LECOM) - Pennsylvania
Pacific Northwest University
of Health Sciences College of
Osteopathic Medicine
(PNWU-COM) - Wash...
Washington State University
(Pullman Campus) Washington
Geisinger Commonwealth
School of Medicine Pennsylvania

Specialty Loookup
Table

9.4 U.S. Board
Certifications and
Specialty

Aerospace medicine
Allergy and immunology
Clinical and laboratory
immunology
Anesthesiology

Neurological surgery
Endovascular surgical
neuroradiology
Neurology
Child neurology
Orthopaedic sports medicine

Pediatric
hematology/oncology
Pediatric infectious diseases
Pediatric nephrology
Pediatric pulmonology
Pediatric rheumatology

Addiction psychiatry
Musculoskeletal oncology
Child and adolescent
psychiatry
Forensic psychiatry
Geriatric psychiatry

192

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module

Languages Lookup
Table

9.8 Language Skills

Adult Cardiothoracic
Anesthesiology
Pediatric anesthesiology
Colon and rectal surgery
Dermatology
Dermatopathology
Procedural dermatology
Emergency medicine
Pediatric emergency medicine
Family medicine
Internal medicine
Cardiovascular disease
Clinical cardiac electrophysiology
Critical care medicine
Endocrinology, diabetes, and
metabolism
Gastroenterology
Geriatric medicine
Hematology and oncology
Infectious disease
Interventional cardiology
Nephrology
Oncology
Pulmonary disease
Pulmonary disease and critical
care medicine
Rheumatology
Sports medicine
Transplant hepatology
Medical genetics
Molecular genetic pathology

Orthopaedic surgery of the
spine
Orthopaedic trauma
Pediatric orthopaedics
Otolaryngology
Neurotology
Pediatric otolaryngology
Palliative and hospice care
Pathology-anatomic and
clinical
Blood banking/transfusion
medicine
Chemical pathology
Cytopathology
Forensic pathology
Hematology
Medical microbiology
Neuropathology
Pediatric pathology
Selective pathology
Pediatrics
Adolescent medicine
Neonatal-perinatal medicine
Pediatric cardiology
Pediatric critical care
medicine
Pediatric emergency
medicine
Pediatric endocrinology
Pediatric gastroenterology

Pediatric sports medicine
Developmental-behavioral
pediatrics
Physical medicine and
rehabilitation
Pediatric rehabilitation
Spinal cord injury medicine
Plastic surgery
Craniofacial surgery
Clinical neurophysiology
Neuromuscular medicine
Preventive medicine
(General/PH)
Neurodevelopmental
disabilities
Preventive medicine (CDC
PMR/F ONLY)
Vascular neurology
Nuclear medicine
Obstetrics and gynecology
Occupational medicine
Medical toxicology
Undersea and hyperbaric
medicine
Ophthalmology
Orthopaedic surgery
Adult reconstructive
orthopaedics
Foot and ankle orthopaedics
Psychiatry

Pain medicine
Psychosomatic medicine
Radiation oncology
Radiology, diagnostic
Abdominal radiology
Cardiothoracic radiology
Musculoskeletal radiology
Pediatric radiology
Neuroradiology
Nuclear radiology
Vascular and interventional
radiology
Sleep medicine
Surgery
Hand surgery
Pediatric surgery
Surgical critical care
Vascular surgery
Vascular surgery ? Integrated
Thoracic surgery
Congenital Cardiac Surgery
Urology
Pediatric urology
Transitional year
Internal Medicine/Pediatrics

English
Afrikaans
Albanian
Amharic
Arabic (Egyptian)
Aramaic
Armenian
Assamese
Aymara
Azerbaijani
Basque
Belarusian
Bengali
Bislama
Bosnian
Bulgarian
Burmese
Catalan
Cebuano
Cherokee
Mandarin
Croatian
Czech
Danish
Dutch
Egyptian
Estonian
Finnish
French
Georgian
German

Hindi
Hungarian
Icelandic
Irish
Italian
Japanese
Javanese
Kannada
Kazakh
Khmer
Korean
Lao
Latvian
Lithuanian
Macedonian
Malagasy
Malayalam
Marathi
Mongolian
Nahuatl
Navajo
Nepali
Norwegian
Oriya
Oromo
Farsi
Polish
Portuguese
Punjabi
Pashto
Romanian

Spanish
Swahili
Swedish
Tagalog
Tajik
Tamil Telugu
Thai
Tibetan
Tok Pisin
Turkish
Turkmen
Ukrainian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Yiddish
Yoruba
Zapotec
Zulu
Arabic (Levantine)
Arabic (Modern Standard)
Arabic (Moroccan)
Indonesian (Not Specified)
Bahasa Melayu
Balochi
Berber
Cantonese
Dari
Ilokano

Uyghur
Yucatec Maya
Arabic (Not Specified)
Chinese (Not Specified)
Creole (Not Specified)
Malay
Other Spoken Language:

193

Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023

Attachment 3 – FMS Application Module
Greek
Guarani
Gujarati
Creole (Haitian)
Hausa
Hawaiian
Hebrew

Romany
Russian
Sanskrit
Serbian
Slovak
Slovenian
Somali

Inuit
Kurdi
Kyrgyz
Lakota
Ojibwa
Quechua
Quiche

194

File Type	application/pdf
File Modified	2021-06-08
File Created	2021-06-08