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aBCpxq44oHti5ReALLH4vR2SF76SA958ZTRibPKgBeUhoBPqjaLCejMMoooyLgoCbFmCsvMrxSxrg22vHxiC3sxxdeyzjSr7R5rSPHUf4dCGLVLPEXe

PROUD-MED Letter of Intent

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The Program for Underrepresented in Medicine for Equity and Diversity (PROUD-MED) is dedicated to the career development, recruitment, appointment and retention of URIM clinician scientists as essential contributors to the translational science workforce. PROUD-MED applicants should identify as a member of those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population (AAMC definition of Underrepresented in Medicine).

Please complete the survey below.

Thank you!

Last Name:

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First Name:

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Middle Initial:

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Primary Street Address:

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Primary Address City and State:

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Primary Address Zip Code:

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Secondary Address: (Street, City, State, ZIP CODE)

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Do you currently hold an appointment at Washington University School of Medicine?

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If NO to the above question, when does your appointment begin? (MM/DD/YYYY)

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M-D-Y

Please provide your current Institution:

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If currently at Washington University, please provide your WUSTL ID:

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Are you a current member of the ICTS?

If No, please register to become an ICTS member to continue with the PROUD-MED Letter of Intent application.

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Yes

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Do you have an eRA Commons ID?
(You will need this ID to submit federal grants)

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Yes

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I do not have an eRA Commons ID, but I will obtain an eRA Commons ID by the full application deadline.
Visit: https://www.era.nih.gov/register-accounts

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True

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Please enter your eRA Commons ID:

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Do you have an ORCiD:
(an ORCiD is required for federal training grants)

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Yes

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I will obtain an ORCiD by the full application deadline.
Visit: https://orcid.org/register to create your ID.

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True

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Please enter your ORCID:

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Please provide a current email address:

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Please provide a secondary email address:

Phone number (mobile):

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Phone number (work):

Date of birth (MM/DD/YYYY):

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M-D-Y

State of Birth:
(If you were NOT born in the US, please enter N/A)

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Country of birth:

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Ethnicity:

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Hispanic or Latina/o/x NOT Hispanic or Latina/o/x

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Race:

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If you listed Other for the above question, please specify:

Which term best expresses your gender identity?

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Male (cis or trans)

Female (cis or trans)

Non-binary/non-conforming

Other gender

Prefer not to respond

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If you chose 'Other gender' from the options above, please specify:

What are your preferred pronouns?

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If you chose 'Other' pronouns from above, please specify:

According to the NIH, An individual is considered to be from a disadvantaged background if s/he meets two or more of the following criteria:

Were or currently are homeless, as defined by the McKinney-Vento Homeless Assistance Act (Definition: https://nche.ed.gov/mckinney-vento/);
Were or currently are in the foster care system, as defined by the Administration for Children and Families (Definition: https://www.acf.hhs.gov/cb/focus-areas/foster-care);
Were eligible for the Federal Free and Reduced Lunch Program for two or more years (Definition: https://www.fns.usda.gov/school-meals/income-eligibility-guidelines);
Have/had no parents or legal guardians who completed a bachelor's degree (see https://nces.ed.gov/pubs2018/2018009.pdf);
Were or currently are eligible for Federal Pell grants (Definition: https://www2.ed.gov/programs/fpg/eligibility.html);
Received support from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as a parent or child (Definition: https://www.fns.usda.gov/wic/wic-eligibility-requirements).
Grew up in one of the following areas: a) a U.S. rural area, as designated by the Health Resources and Services Administration (HRSA) Rural Health Grants Eligibility Analyzer (https://data.hrsa.gov/tools/rural-health), or b) a Centers for Medicare and Medicaid Services-designated Low-Income and Health Professional Shortage Areas (qualifying zip codes are included in the file). Only one of the two possibilities in #7 can be used as a criterion for the disadvantaged background definition.

Do you meet the NIH's definition as an individual from a disadvantaged background?

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Yes No Prefer not to respond

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The PROUD-MED program at Washington University in St. Louis is an inclusive organization. The choices in the previous questions are not meant to be an exhaustive list for identifying diverse and underrepresented populations.
If you are from a diverse, disadvantaged, and/or underrepresented population NOT listed above, please provide a brief explanation.

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Do you have a disability?

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If Yes, please describe your disability by checking all that apply:

* must provide value

Hearing loss

Vision loss

Loss of ability to speak

Loss of use of one or more limbs

Disabling systemic illness

Disabling mental illness

Disabling pain

Other

If you chose 'Other' disability, please specify:

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Applicant Clinical Degree(s)*: Please note that you must hold a clinical degree to be eligible. Please check all that apply:

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MBBS

Other clinical degree

If you chose 'Other clinical degree', please specify (PharmD, PsyD, etc.):

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Please list any additional degrees. Check all that apply.

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PhD

MPH

MSCI

Other degree

If you chose 'Other degree', please specify:

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Provide the month and year when your clinical* degree was received: (MM/YYYY):

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Provide the clinical* degree granting institution(s) :

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Location of clinical* degree granting institution(s) (city, state, country):

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Did you complete your clinical* residency?

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Yes

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If 'YES', when did you complete your clinical residency? (MM/YYYY):

* must provide value

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Where did you complete your clinical residency?

* must provide value

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If 'NO', when and where do you expect to complete your residency? (MM/YYYY)

* must provide value

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Academic rank:

* must provide value

Department of your primary training or faculty appointment at WUSM:

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What is your division within the Department of Internal Medicine?

* must provide value

Allergy and Immunology

Bioorganic Chemistry and Molecular Pharmacology

Bone and Mineral Diseases

Cardiology/Cardiovascular Diseases

Dermatology

Endocrinology/Metabolism/Lipid Research

Gastroenterology

General Medical Sciences

General Medicine

Geriatrics and Nutritional Sciences

Hematology

Hospital Medicine

Infectious Diseases

Nephrology

Oncology

Palliative Medicine

Pulmonary and Critical Care Medicine

Rheumatology

Veterans Affairs

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What is your division within the Department of Pediatrics?

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Adolescent Medicine

Allergy and Pulmonary Medicine

Cardiology

Critical Care Medicine

Emergency Medicine

Endocrinology and Diabetes

Gastroenterology, Hepatology and Nutrition

Genetics and Genomic Medicine

Hematology and Oncology

Hospitalist Medicine

Infectious Diseases

Nephrology, Hypertension and Pheresis

Newborn Medicine

Rheumatology and Immunology

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What is your division within the Department of Radiology?

* must provide value

Diagnostic

Nuclear Medicine

Radiological Sciences

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What is your division within the Department of Surgery?

* must provide value

Cardiothoracic Surgery

General Surgery

Pediatric Surgery

Plastic and Reconstructive Surgery

Urologic Surgery

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Provide the name of your Department Chair/Division Chief who will write the Letter of Nomination:

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Chair/chief email address:

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Personal assistant name:

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Personal assistant email address:

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