0920-23DP PHL Fellowship Host Site Application

Form approved

OMB No. 0920-XXXX

Expiration date: XX/XX/XXXX

Public Health Law Fellowship — Host Site Application

To apply as a host site to the Public Health Law Fellowship, please complete the survey below.

To complete this survey, please select the answer that applies to each question posed below. If it is possible to choose more than one answer, the question will have an instruction to select all that apply.

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Before submitting your survey, you may save your progress and return later to complete the survey by selecting the “Save & Return Later” option at the bottom of the page. If you select “Save & Return Later,” you will be given a return code when leaving a survey. The return code is required to re-enter and finish the survey. We are not able to retrieve lost codes, so if you cannot find your code, you will need to restart the survey. Selecting “Save & Return Later” does not submit your answers.

To submit your answers, you must select “Submit.” Your survey responses will be submitted, and you will see a survey completion note thanking you for your submission. You will not be able to edit your responses once your survey is submitted. You will be able to download a PDF of your application responses if you would like to.  

Thank you!

Public reporting burden of this collection of information is estimated to average 21 minutes per response, including the time for reviewing the 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 aspects of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Information Collection Review Office, 1600 Clifton Rd. NE, MS H21-8, Atlanta, GA 30329; ATTN: PRA (0920-XXXX). 

Name of fellow's preceptor __________________________________

Work email address of fellow's preceptor __________________________________

Work phone number of fellow's preceptor __________________________________

Which of the following degrees does the fellow's preceptor hold?

• JD

• Master of public health

• Master of public administration

• Master of public policy

• PhD

• DrPH

• Other

Describe the preceptor's current role on your team _________________________

Rate the preceptor's professional experience level with public health law/policy

• Very high

• High

• Moderate

• Low

• Very low

Rate the preceptor's professional experience level with emergency preparedness and response

• Very high

• High

• Moderate

• Low

• Very low

Rate the preceptor's experience level applying public health equity principles to public health practice

• Very high

• High

• Moderate

• Low

• Very low

What is the name of your organization? ________________________

Please select the option below that best describes your organization

• CDC

• Other federal agency

• State

• Local

• Territorial

• Tribal

• Community-based organization

• University/academia

• Private public health organization

• Nonprofit organization

• Other _____________________

What is the name of your department or office within your agency? ____________________________

Briefly describe your office's role in your organization. __________________________________

Where is your organization located?

City/town: ___________________

State/province: _______________________

ZIP/postal code: ____________________

Which of the following best describes your health department's jurisdiction? Check all that apply.

• Urban

• Suburban

• Rural

Please estimate the number of people your organization serves through its jurisdiction. ___________________________________

Do you have a letter of support from your office's leaders?

• Yes

• No

Please upload your letter of support.

Which of the following public health law and policy topics do you plan on having your fellow work on? Please select up to three.

• Health equity

• Vaccination

• Emergency preparedness and response

• Environmental Health

• Maternal and child health

• Coroner/medical death investigation laws

• Public health data systems

• General legal counsel/clerkship

• Other (please specify) ______

Briefly describe the projects you plan to have the fellow work on, including desired outcomes and products. __________________________________

Please describe the population or demographics you seek to serve through your fellow's work.

__________________________________

Will your fellow's work support your organization's capacity to improve public health equity or emergency preparedness?

• Health equity

• Emergency preparedness

• Neither

Please explain how your fellow's work support your organization's capacity to improve health equity.

__________________________________

Please explain how your fellow's work support your organization's capacity to improve emergency preparedness.

__________________________________

Please describe the type of support and supervision you plan to offer to your fellow, in terms of professional mentoring, collaboration, and guidance within the scope of their work assignments.

__________________________________

How do you prefer your fellow to work?

• Onsite

• Remote/virtual

• Hybrid

Please describe what level of facility and technical access your fellow will have (e.g., will you be assigning a laptop, will the fellow have access to an organizational email account, building access?).

__________________________________

What is your preference for education completion?

• I am okay with a fellow who has completed their degree

• I am okay with in-progress students

• Either/both

What educational background would you prefer your fellow to have? (Note: The fellow may be a current student seeking the below degree. Preference is not guaranteed).

• JD

• Master of public health

• Either

• Both

• Other master's degree (please specify what kind) ______

Does your state have specific requirements regarding the Bar Exam?

• Yes, UBE

• Yes, MBE

• No

• Not sure

Rank your preference for fellowship duration

1st Choice 2nd Choice 3rd Choice

• 1 semester (summer, fall, or spring)

• 2 semesters (fall to spring, academic year)

• 1 year (full calendar year)

Requested number of fellows __________________________________

You have requested more than one fellow. Will they be working on the same project and have the same mentoring? __________________________________

Does your agency plan to work with any external partners for fellowship project work?

• Yes

• No

Please describe the partners and their role. __________________________________