PHMC 2023 Application

2023-2024 Application
Section 1: Applicant Information
Name*

First NameMiddle NameLast NameSuffix
Work Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail*
Organization*
Department*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Position Title*
In your own words, please describe your current responsibilities and management activities in your organization (for example, program-level, mid-level, or senior-level management; non-manager; new or experienced manager). Also, if applicable, please describe the duties and management activities to which you aspire or for which you are preparing yourself.
Current Responsibilities*
The Public Health Management Certificate is seeking to better incorporate equity, diversity, and inclusion as an integral part of its program environment, operations, and curriculum. To you, why is it important that a manager promote equity, diversity, and inclusion within their organization or program?
*
Section 2: Background Questions
The Public Health Management Certificate (PHMC) would like to know how the program came to your attention. Select the source which had the biggest influence on your decision to apply to the program.
I heard about PHMC through (check all that apply):*

Postcard or flyerWebsiteSocial media (Facebook, LinkedIn)Past attendeeColleagueNWCPHP staff or facultyE-mail announcementWebinarConference, meeting, or eventManager or supervisorOther word of mouth
Employment status (check one)*

Full-timePart-timeVolunteer
Job category*
What type of organization do you work for?*

Local/county health departmentState health departmentTribe or tribal-serving organizationCommunity-based or nonprofit organizationHospital, medical center, clinic, or other health delivery centerFederal agency
Number of years in public health or related field (check one)*

0–1 years2–4 years5–9 years10 years or more
Number of years in current position (check one)*

0–1 years2–4 years5–9 years10 years or more
Do you work in a rural area?*

YesNo
Do you work in a medically underserved community?*

YesNo
Do you work in a primary care setting?*

YesNo
The following information is collected for statistical purposes for reporting to funding organizations and is not used as admission criteria, nor will it be used to identify individual scholars:
Gender Identity*

ManWomanTransgenderGenderqueer/Non-binaryTwo-SpiritAgenderPrefer not to respond
Ethnicity (check all/any that apply)*

Alaska Native / American IndianAsianBlack / African AmericanLatino / Spanish / HispanicNative Hawaiian / Other Pacific IslanderMixed-raceWhitePrefer not to respond
Is English your preferred language?*

YesNo (please specify your preferred language below)
Specify your preferred language if you selected "No" above
Do you identify yourself as a person with disability?

YesNoPrefer not to say
Age*

20–2930–3940–4950–5960+Prefer not to respond
Degrees earned:
Please list all/any here
Section 3: Narrative Statement
Write a narrative statement of no more than 500 words that describes a current management goal. Please also include information about what you expect to gain from participating in the program and how you hope to use the skills you develop during the program.

You may type your statement below or upload a file, if you prefer.
Current management goal:*
Narrative statement upload option (if you prefer not to type above):
Section 4: CV/Résumé
Please upload a copy of your CV/résumé. It should include your educational and employment history as well as any professional memberships and activities.
Please upload CV/résumé here:*
Section 5: Letter of Support
A letter of support from your agency director must be submitted as part of the application process. You may upload a scanned copy of your letter of support, or send it to Sarah Manchanda, University of Washington, NWCPHP - Public Health Management Certificate, Box 351621, Seattle, WA 98195 or at paliulis@uw.edu.
Please upload letter of support here:
Section 6: Program Requirements
Program Requirements Document (pdf)

Download, sign, and upload a scanned copy of your program requirements document, or send it to Sarah Manchanda, University of Washington, NWCPHP - Public Health Management Certificate, Box 351621, Seattle, WA 98195 or at paliulis@uw.edu.
Signed program requirements document (please download pdf above, sign, and upload here):
Section 7: Application Checklist, Submission, and Next Steps
Application checklist

You may submit this online application form before the other documents. For a full application, the following five documents are required. The narrative statement, CV/résumé, and program requirements document can be emailed, mailed, or faxed to the contact below.
1. Basic information (sections 1 and 2)
2. Narrative statement (section 3 - upload or type in above)
3. CV/résumé (section 4 - upload above)
4. Letter of support from agency director (section 5 - upload above)
5. Program requirements document signed by applicant and immediate supervisor (section 6 - download above, sign, upload)
6. Optional: scholarship application (at end of this form)
Application Due Date and Payment

Deadline: The final application deadline for the 2023-24 program year is May 31, 2023. Early bird applicants will be notified of acceptance by April 19. Applicants will be notified of acceptance by June 7, 2023.

Early bird: In order to receive the $4,500 discount rate, completed applications must be received by April 14, 2023. After that date, and until the deadline, the regular program price is $5,000.

Once you are accepted into the program, you will receive instructions on how to submit your payment.

Please contact us if your department needs an invoice or payment form or if you plan to pay by check.

Applications may be submitted electronically here (including electronic signatures or as scanned PDFs of the original program requirements printed document) or, if necessary, sent to Sarah Manchanda (paliulis@uw.edu).

Cancellation: For the cancellation policy, see the program requirements.
Section 8: (Optional) Scholarship Application
Are you interested in applying for partial scholarship funding?

YesNoNot sure at this time
If you'll be applying for partial scholarship, please fill out the following fields.

The Public Health Management Certificate Program may be offering partial scholarships to eligible participants based on funding availability and participant need.
How much funding are you requesting and what will the funds cover? (Please remember: funds may be limited)
Why do you need this financial support?
Can your agency provide partial support for funding your attendance? How much support might they be able to provide?
Should be Empty:

2023-2024 Application

Section 1: Applicant Information

Section 2: Background Questions

Section 3: Narrative Statement

Section 4: CV/Résumé

Section 5: Letter of Support

Section 6: Program Requirements

Section 7: Application Checklist, Submission, and Next Steps

Section 8: (Optional) Scholarship Application