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Scholars for a Healthy Oregon Initiative Application

Returning?

A A A

Please allow one hour to complete the Scholars for a Healthy Oregon Application. There is a "save and return" option for respondents that cannot complete their application in one session. If you have any questions, please contact Anna Tupper at tupper@ohsu.edu or (503) 494-1267.

2019-2020 SHOI Application ID

Please review all OHSU policies and Service Agreement (found at www.ohsu.edu/healthyoregon) before completing this application.

Thank you for your interest in the Scholars for a Healthy Oregon Initiative (SHOI) funding. The initiative is intended to address issues related to high tuition and the shortage of healthcare professionals in Oregon's rural and underserved communities.

Applications for the SHOI funding are available to students applying to OHSU in the 2019-2020 Academic Year in select academic programs:

Doctor of Medicine (MD)
Doctor of Dental Medicine (DMD)
Master of Physician Assistant Studies (MPAS)
Doctor of Nursing Practice in:
a) Nurse Anesthesia
b) Family Nurse Practitioner
c) Nurse Midwifery
d) Psychiatric Mental Health Nurse Practitioner
e) Pediatric Nurse Practitioner
f) Adult Gerontology Acute Care Nurse Practitioner

AND

Applicants must be either Oregon Residents or can demonstrate Oregon Heritage (policy 02-10-025) under OHSU Admissions Criteria (PDF copy below).

For those who meet the above criteria, preference is given to students who:

1. Graduated from one of four Technical and Regional Universities (Eastern Oregon University, Oregon Tech, Southern Oregon University or Western Oregon University)
2. Are first generation college students
3. Are from a diverse or under-represented community

This application includes demographic data, essay questions and optional identifying information. You may save and return to your work if you are not able to complete in one session. We encourage you to answer all questions. Leaving questions blank (except for optional questions relating to gender, ethnicity and race) may constrain the SHOI Selection Committee from conducting a thorough review of your application.

By submitting this application, you authorize the OHSU School of Medicine, Dentistry, Nursing or Physician Assistant program to release the information you provided on your admissions application to the SHOI Selection Committee. If you have any questions, please contact Anna Tupper at (503)494-1267 or tupper@ohsu.edu.

I have read, understand and agree to the program obligations for the Scholars for a Healthy Oregon Initiative funding:

True

False

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ELIGIBILITY DETERMINATION:

OHSU Residency Policy 02-10-010

Attachment:OHSU Residency Policy 02-10-010.pdf

Do you qualify for Oregon Residency under OHSU policy 02-10-010?

* must provide value

Yes

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Legal state of residence when applying to OHSU?

OHSU Oregon Heritage Policy 02-10-025

Attachment:OHSU Oregon-Heritage-02-10-025.pdf

Do you qualify for Oregon Heritage under OHSU policy 02-10-025?

* must provide value

Yes

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Last Name

* must provide value

First Name

* must provide value

Address

* must provide value

City/Town

* must provide value

State

* must provide value

Zip Code:

* must provide value

Phone Number:

* must provide value

Email Address:

* must provide value

Application Service Number (this is your CASPA, AMCAS, AADSAS or Nursing CAS). If you do not have an Application Service Number, please leave blank.

OHSU ID Number (if known):

Gender:

Male

Female

Other

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What is your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

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What is your race?(check all that apply)

American Indian or Alaska Native

Chinese

Filipino

Indian

Japanese

Korean

Vietnamese

Asian

Black or African American

Native Hawaiian or other Pacific Islander

Eastern European

Middle Eastern

White

Other

List the name of the high school and location (city/state) from which you graduated:

* must provide value

Which program are you applying to?

* must provide value

OHSU School of Dentistry (DMD)

OHSU School of Medicine (MD)

OHSU Master of Physician Assistant Studies (MPAS)

OHSU Doctor of Nursing Practice (DNP)

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OHSU Doctor of Nursing Practice in:

* must provide value

Adult Gerontology Acute Care Nurse Practitioner

Nurse Anesthesia

Family Nurse Practitioner

Nurse Midwifery

Pediatric Nurse Practitioner

Psychiatric Mental Health Nurse Practitioner

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Do you plan to pursue any other degree program(s) after/in conjunction with the above?

* must provide value

Yes

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Name of degree program:

Have you, or will you, apply for any of the following programs (check all that apply):

National Health Service Corps Scholar

Military Scholarship/Obligation

Indian Health Service Corps

Other program with obligated service after training

Name of program with service after training obligation:

Bachelor Degree

Master Degree

Doctoral Degree

Other

Obtained from a Oregon College or University

Obtained from a non-Oregon College or University

List the name of the college or university where you earned your Bachelor Degree and its location (city/state).

* must provide value

List the name of the college or university where you earned your Master Degree and its location (city/state).

* must provide value

List the name of the college or university where you earned your Doctoral Degree and its location (city/state).

* must provide value

List the name of the college or university where you earned your "other degree" and its location (city/state).

* must provide value

Are you proficient in any language(s) other than English?

Yes

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Language 1

Language 1 proficiency

Basic

Intermediate

Fluent

Native/Bilingual

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Language 2

Language Proficiency 2

Basic

Intermediate

Fluent

Native/Bilingual

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Language 3

Language 3 Proficiency

Basic

Intermediate

Fluent

Native/Bilingual

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What is the name of the primary place you lived (city/town, state and country) prior to 18 years of age?

* must provide value

What is the population of the primary place you lived prior to 18 years of age?

* must provide value

Rural (< 40,000 and not within 10 miles of a city with a population of 40,000)

Suburban (within commuting distance of a city)

Mid-sized City (40,000-99,999)

Large City (100,000-999,999)

Urban (>1,000,000)

No response

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Do you believe that the area you lived in during childhood was medically underserved? (Defined as an area with a high percentage of the population below the poverty level; a high percentage of the population that is elderly; a high infant mortality rate; and/or a lack of available primary care physicians).

* must provide value

Yes

Unknown

No Response

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Highest level of education attained by parent/guardian #1:

Unknown

No formal education

Kindergarten - 8th grade

High school graduate/GED

Some College

Associate's degree

Bachelor's degree

Graduate degree or higher

No response

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Highest level of education attained by parent/guardian #2:

Unknown

No formal education

Kindergarten - 8th grade

High school graduate/GED

Some College

Associate's degree

Bachelor's degree

Graduate degree or higher

No response

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None

Mild

Moderate

Severe

No Response

Economic

Educational

Ethnic/cultural

Family

Please describe the nature of the adversity that you experienced (250 word maximum):

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At OHSU, we embrace the full spectrum of diversity, including age, color, culture, disability, ethnicity, gender identity or expression, marital status, national origin, race, religion, sex, sexual orientation, and socioeconomic status. We respect and support diversity of thought, ideas and more. To fully leverage the richness of our diversity at OHSU, we must create, maintain and promote a community of inclusion. Inclusion means we honor, respect, embrace and value the unique contributions and perspectives of all employees, patients, students, volunteers and our local and global communities. It also includes removing barriers to individual success.

Using the statement above as a guide, please discuss the diversity that you would bring to OHSU, and how you will integrate diversity and inclusion into your chosen profession (1000 word maximum).

* must provide value

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SHOI funding provides full tuition and mandatory fees (for the normal length of the degree program) for a limited number of eligible students entering specific degree programs at OHSU. In return, funding recipients agree to practice as a healthcare practitioner at a Designated Service Site in Oregon for a minimum of one year longer than the total years of funding received. Designated Service Sites may include critical access hospitals, federally qualified health centers or any geographic area, population group or facility that is located in Oregon and has been designated by the Health Resources and Services Administration of the Department of Health and Human Services as a health professional shortage area, a medically underserved area or a medically underserved population. Designated Service Sites are based on State and Federal shortage designation criteria therefore are determined on the year of program completion.

The Scholars for a Healthy Oregon Initiative funding was created to address the shortage of healthcare professionals in Oregon's rural or underserved communities. In your responses to the following questions, please demonstrate your understanding of the service commitment and your role in caring for rural and/or underserved Oregonians at a Designated Service Site.

Describe the practice location characteristics, population and community you plan to serve in the future as a health care professional. (1000 word maximum)

* must provide value

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What attributes and/or experience do you have that demonstrates your commitment to these communities and your ability to successfully fulfill your service commitment at a Designated Service Site? (1000 word maximum)

* must provide value

Expand

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