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6nzXdz2fINstjQo8z3KY6zn9TMyKJPKEUTxqU8XWvmyKksJW5myHbrPCif

HCOP Ambassadors Application

WASHINGTON STATE UW Health Careers Opportunity Grant (HCOP)

Cohort Year

* must provide value

This is the application for the two-year interprofessional HCOP Ambassadors Program offered by the Office of Rural Programs at the University of Washington School of Medicine (the "WA HCOP Program Office") . Eligible students must be in a health professional program that ends in a certificate or degree, after which students will be qualified to find work in their field or discipline. All students who complete the program will receive a certificate of completion. This is a nationwide Health Resources and Services Administration ("HRSA") program that will identify HCOP Ambassadors as having special training and experience with rural and underserved communities. The program is meant to help empower disadvantaged students to complete their degree and enter healthcare careers. It includes training in health disparities, health equity, and social determinants of health.

Once received, an administrator will contact you with more information. After further review, you will be notified regarding the status of your application and whether you have been accepted to the program. Thank you for applying!

WA HCOP Ambassadors Privacy Notice ("Privacy Notice")
By applying to be a WA HCOP Ambassador, the WA Program Office will collect personal data through the responses you provide below in this application ("Application Data"). If you do not provide your personal data in this application, the Program Office will not be able to evaluate your candidacy.

If you are selected to be an HCOP Ambassador, the WA Program Office will collect additional personal data through surveys during your time as an HCOP Ambassador and after you graduate which may include your academic concentration, specialty, level of education, race, ethnicity, gender, veteran status, language fluency, economic background, post-graduation employment, and similar demographic information ("Survey Data"). HCOP Ambassador Program and instruction. Personal data will be maintained in a Program Office database that is only accessed by a Program Office faculty and staff with a legitimate need to access your personal data.

The WA Program Office is required to report certain Application Data and Survey Data to the Health Resources and Services Administration ("HRSA") of the U.S. Department of Health and Human Services which funds the HCOP Academy and evaluates HCOP programs around the country. For HRSA reporting, all HCOP Ambassadors will have unique identifiers. These identifiers will also be used to track former HCOP Ambassadors who are later employed in underserved healthcare. Personal data reported to HRSA will not include your name, email addresses, home address, or phone number (that personal data will remain with the WA Program Office).

Additionally, the WA Program Office may share Application Data and Survey Data (1) with third-party contractors (ex. cloud solutions providers), and (2) to comply with a valid legal process, governmental request, or applicable law, rule or regulation.

If you have questions about the collection, use or sharing of your personal data, you may contact the WA Program Office at slmorr01@uw.edu. University of Washington students may learn more about the Family Educational Rights and Privacy Act ("FERPA") by clicking here.

Email address

* must provide value

alternate personal email address-for post program contact

* must provide value

First name

* must provide value

Last name

* must provide value

Street address

* must provide value

City

* must provide value

State

* must provide value

Zip code

* must provide value

Mobile phone

* must provide value

Date of birth

* must provide value

M-D-Y

Please check the following race or ethnicity in which you identify. The Revisions to OMB Directive 15 defines each racial and ethnic category as follows:

* must provide value

American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."

Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to "Hispanic or Latino."

Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Other

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If Other, please explain

What is your ethnicity?

* must provide value

Hispanic Non-Latino

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Please check the gender with which you identify

* must provide value

Female Male Transgender or Nonbinary or another gender

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All applicants must meet the following critieria:
• Economically or educationally disadvantaged background criteria, and,
• Must be a citizen, non-citizen national of the United States, an individual lawfully admitted for permanent residence to the United States, or any other "qualified alien" under section 431(b) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. 104-193, as amended. Individuals on temporary or student visas are NOT eligible for the program.

Are you a U.S. Citizen or do you have a green card and permanent resident status?

* must provide value

Yes No

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If not a U.S. Citizen or green card holder, are you an international student on a student visa or a DACA student?

* must provide value

Yes No

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Demographics: Background questions
The HCOP Ambassadors program is designed to specificallly train disadvantaged students. To qualify you MUST meet the HRSA definition of disadvantaged status for this grant is as follows:

Individuals are considered from an "economically disadvantaged" background if they come from a family with an annual income below a level based on low-income thresholds. The U.S. Department of Health and Human Services (HHS) Secretary defines a ''low-income family/household'' for various health professions programs included in Titles III, VII and VIII of the Public Health Service Act, as having an annual income that does not exceed 200 percent of the Department's poverty guidelines. A family is a group of two or more individuals related by birth, marriage, or adoption who live together. A household may be only one person. Applicants are required to utilize the 2023 Poverty Guideline table below, published by HHS, to determine an individual's disadvantage status.

If an individual does not qualify as "economically disadvantaged," applicants must indicate that they qualify as "educationally disadvantaged."
Individuals are considered from an "educationally disadvantaged" background if they come from a social, cultural, or educational environment that has demonstrably and directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a health professions education or training program. Applicants must use the criteria below to classify student participants as coming from educationally disadvantaged backgrounds. The National HCOP Academies' participants must meet one or more of the following criteria to qualify under the educationally disadvantaged background status:
• Is first-generation in their family to attend college.
• Graduated from (or attended) a high school, based on the most recent annual data available, which either had a:
o Low percentage of seniors receiving a high school diploma; or
o Low percentage of high school graduates who attend college the following year after graduation.
• Graduated from (or attended) a high school with low per capita funding.
• Graduated from (or attended) a high school where - based on the most recent annual data available - many of the enrolled students are eligible for free or reduced-price lunches.

Attachment:2023-00885.pdf

Are you economically disadvantaged based on the federal HHS definition? (see definition in section above and tables in pdf)

* must provide value

Yes

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Educationally disadvantaged status: please check as many as apply

* must provide value

I am the first in my family to go to college

Graduated from or attended a high school where many of the enrolled students were eligible for free or reduced lunches.

Graduated or attended from a high school with a low percentage of seniors receiving a diploma

Graduated or attended from a high school with a low percentage of graduates who went on to attend college.

Graduated from or attended a high school with low per capita funding

None of the above

If you answered yes to any of the questions regarding your high school experience, please tell us what high school in what state and city or town.

* must provide value

Veteran Status

* must provide value

If a veteran, what is your veteran status?

Active Duty Military National Guard Veteran - prior service Reservist Veteran-retired

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Please indicate the type of community you grew up in or consider yourself from.

* must provide value

Please explain

* must provide value

Are you from a non-rural urban underserved community?

* must provide value

Yes No Maybe

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Where? What community?

* must provide value

Have you ever worked or volunteered in a rural or underserved community in community or health-related service?

* must provide value

Yes No

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Where and in what capacity?

* must provide value

How long did you do this work or volunteering?

* must provide value

What is your school or university?

* must provide value

What is your enrollment status?

full time part-time

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What is the name of your program or major?

* must provide value

What discipline are you pursuing in your primary program?

* must provide value

What degree will you be earning?

* must provide value

Are you specializing in something? For example, you are in a nursing program, with a specialty in midwifery

What year of your program are you in?

* must provide value

1st year

2nd year

3rd Year

Fourth Year

Fifth Year

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When (what month and year) do you anticipate graduating from your primary program?

* must provide value

If you have completed at least one quarter/semester of your health professional program, do you have at least a 2.5 GPA?*

*Currently enrolled students must have a 2.5 GPA to apply. Though GPA does not apply to incoming students, all students who enroll in the HCOP Ambassadors program must remain in good standing with their primary program to remain in HCOP Ambassadors program.

* must provide value

Yes

Does not apply to me

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Please indicate the setting in which you plan to WORK after the completion of your medical education.

* must provide value

Specify other

I understand that the requirements of the two year HCOP Ambassadors includes: completing a clinical rotation in a rural or urban underserved area, completing required a synchronous modules, completing a research project to be presented at a symposium or conference, and mentoring a younger student or students interested in a potential healthcare career.

* must provide value

Yes

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I understand I will qualify for stipends if accepted into the HCOP Ambassadors program (amount to be determined by the program based on available funding ).

* must provide value

Yes

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In 250-500 words, please write a brief explanation about why you are interested in being an HCOP Ambassador.

* must provide value

Expand

By submitting this application to the HCOP Program Office, you:

Confirm that you have read and understood the Privacy Notice that appears above;

Agree to complete all surveys while participating in the HCOP Ambassadors Program;

Agree to be contacted one year after graduation and to complete additional surveys at that time;

Acknowledge that the HCOP Program Office is required to report certain personal data, as described above in the Privacy Notice, to the Health Resources and Services Administration ("HRSA") of the U.S. Department of Health and Human Services; and

Agree to the release of your personal data, as described above in the Privacy Notice, to HRSA for HRSA's own HCOP program evaluations.

Signature

* must provide value

Add signature

Date

* must provide value

M-D-Y

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant FAIN number D1850061 for the WA HCOP Academy through the University of Washington in the total amount of $639,706 for the 2023-2024 fiscal year. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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