Application | Kaiser Permanente Undergraduate & Graduate Medical Education Northern California

Applicant Information

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**Please save a copy of your answers before submission, in the event that the application does not go through and you are asked to submit again.

Name*

First Middle Last

Other Names Used

Date of Birth*

Primary Phone*

Mobile Phone*

Current Address*

Street Address City State / Province / Region ZIP / Postal Code

Email: Academic/Professional*

Email: Personal*

Citizenship*

If not US citizen, current visa:

Have you ever participated at any Kaiser Permanente facility as a medical student, volunteer, fellow, per diem physician, or staff member?*

Yes
No

If yes, please note the following:

Role	Dates	Department	NUID (if applicable)

Languages Spoken and Level of Fluency*

Please indicate language(s) spoken and level(s) of fluency using the following scale: (Basic, Conversational, Advanced, Native/Functionally Native)

Education History

Residency/Fellowship Experience

Do you have more than one Residency/Fellowship experience to report?*

Yes
No

Specialty*

Institution*

Residency Dates*

Start Date	End Date

Program Director

First Name	Last Name	Phone	Email

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Specialty

Institution

Residency Dates

Start Date	End Date

Program Director

First Name	Last Name	Phone	Email

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Specialty

Institution

Residency Dates

Start Date	End Date

Program Director

First Name	Last Name	Phone	Email

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Education History

Medical School Education, Graduate School Education, Undergraduate Education

Medical Education: Institution*

Medical School Dates*

Start Date	End Date

Address

Street Address City State / Province / Region ZIP / Postal Code Country

For International Medical Graduates: ECFMG #

Please attach copy of ECFMG certificate, if applicable:

Max. file size: 50 MB.

Graduate Education: Institution*

Major	Degree

Grad School Dates*

Start Date	End Date

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Graduate Education: Institution

Major	Degree

Grad School Dates

Start Date	End Date

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Undergraduate Education: Institution*

Undergrad Dates*

Start Date	End Date

Major	Degree

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Undergraduate Education: Institution

Undergrad Dates

Start Date	End Date

Major	Degree

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Examinations

List the scores for the USMLE examinations you have completed (note N/A for any not completed):*

USMLE Step 1:	USMLE Step 2:	USMLE Step 3:

List the scores for the COMLEX examinations you have completed (note N/A for any not completed):*

COMLEX Level 1:	COMLEX Level 2:	COMLEX Level 3:

Do any of these scores above reflect multiple examination attempts:

Yes
No

Board certification:*

Passed the board exam
Currently eligible for Board Certification
Not eligible
Will be eligible as of: (enter date below)

Eligibility date for board exam (if box checked above):

Licenses

Do you have a California Medical License?*

Yes
No

List any states in which you are licensed to practice medicine:

State:	License #:	Date Issued:	Expiration:

Do you have DEA registration?*

Yes
No

References

List 3 references who will be submitting letters (one must be your residency program director):

Reference 1: Name

First Last

Title

Email

Phone

Reference 2: Name

First Last

Title

Email

Phone

Reference 3: Name

First Last

Title

Email

Phone

Additional Information

Please describe your past meaningful experiences in community health. (1-2 paragraphs)*

Please describe what you hope to accomplish by completing a fellowship in Community Medicine. (In answering this item, you may wish to include your career goals and/or your community health interests such as clinical, advocacy, policy, QI, or research interests). Clinically, what are your specific community health interests and your current community/research interests? (1-2 paragraphs)*

Please describe your ideal career position after completing the fellowship. (1-2 paragraphs)*

Additional Documents

Please attach the following documents to your application: • Curriculum Vitae • One (1) letter of recommendation from your Residency Program Director • Two (2) additional professional letters of recommendation • USMLE / COMLEX Transcript • Medical School Transcript • MSPE (Dean’s Letter)

Curriculum Vitae*

Max. file size: 50 MB.

One (1) letter of recommendation from your Residency Program Director. [If letter will be sent separately to melissa.m.wong@kp.org, please submit placeholder document.]*

Max. file size: 50 MB.

Two (2) additional professional letters of recommendation. [If letter(s) will be sent separately melissa.m.wong@kp.org, please submit a placeholder document(s).]*

Drop files here or

Max. file size: 50 MB.

USMLE / COMLEX Transcript*

Max. file size: 50 MB.

Medical School Transcript*

Max. file size: 50 MB.

MSPE (Dean’s Letter)*

Max. file size: 50 MB.

Fellowship Preference

Which KP Community Medicine Fellowships do you wish to be considered for?*

(Check all that apply)

Deselect All
Community Medicine and Global Health Fellowship - Napa/Solano
Community Medicine and Vulnerable Populations Fellowship - San Jose
Community Medicine and Urban Health Fellowship – San Francisco
Community Medicine and Health Disparities Fellowship - Oakland

If you indicated that you intend to apply for the Community Medicine & Global Health Fellowship - Napa/Solano, please answer the following questions:*

What previous global health experiences have you had? What was meaningful and what lessons will you incorporate in future trips? What do you hope to gain from future global health experiences? (1-2 paragraphs)

If you indicated that you intend to apply for the Community Medicine & Health Disparities Fellowship - Oakland, please complete the following item:*

Describe an experience that has highlighted for you the impact of health disparities. This could be an encounter with a patient or a broader public health observation.

If you indicated that you intend to apply for the Community Medicine & Public Health Fellowship - Sacramento Valley, please answer the following questions:*

What are your specific population health interests? How would you like to incorporate this in your future career?

If you indicated that you intend to apply for the Community Medicine and Vulnerable Populations Fellowship - San Jose, please answer the following questions:*

What is a specific vulnerable population that you have interest in and why? If applicable, what work have you done with this population in the past? What goals do you have related to working with this group in the future? (1-2 paragraphs)

If you indicated that you intend to apply for the Community Medicine & Faculty Development Fellowship - Santa Rosa, please answer the following questions:*

What previous teaching experiences have you had? How do you see yourself using education to reduce health disparities and/or improving the total health of diverse communities? (1-2 paragraphs)

Attestation*

I certify that the information provided in the application as well as submitted materials are truthful and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me for this position. I further declare that by submitting this application, I authorize Kaiser Permanente and its representatives to contact persons associated with hospitals or institutions at which I have studied or trained as well as individuals whose names I have submitted in connection with this application. I hereby release from any liability all representatives of the hospital and its professional staff for information provided in connection with evaluating my application, suitability for employment or training, and credentials.

By clicking this box, I certify that the information provided, as specified above, is true and correct to the best of my knowledge.

Email

This field is for validation purposes and should be left unchanged.

Community Medicine Fellowships - Application

Community Medicine Fellowships

Applications now open for the 2024-2025 fellowship cycle!

Applicant Information

Education History

Education History

Examinations

Licenses

References

Additional Information

Additional Documents

Fellowship Preference