Community Health Advanced by Medical Practice Superstars (CHAMPS) Program Application

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1. Name* This field is required.

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2. Degree(s)/Credentials(s)* This field is required.Select one

MD

DO

PA

Other (please specify on the next page)

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Please specify your degree(s)/credential(s) if you selected "Other".

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3. With which race do you most closely identify?* This field is required.

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4. Are you Hispanic or Latino/a?* This field is required.

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5. What is your gender identity?* This field is required.

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Please specify your gender identity if you selected "Other."

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6. What language(s) do you speak?* This field is required.

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7. Contact Information* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

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Phone* This field is required.

Area Code

Phone Number

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E-mail* This field is required.

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8. Organizational Contact Information (if different from above)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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Work Phone

Area Code

Phone Number

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Work E-mail

example@example.com

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1. Name of Clinical Practice* This field is required.

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2. Next you will be asked to enter the percent of patients served by your clinical practice that are:

A. Children/youth ages 0-17

B. Adults ages 18-64

C. Older adults ages 65+

Please enter your best estimation.

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A. What percent of your patients are children/youth ages 0-17?* This field is required.Enter a number

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B. What percent of your patients are adults ages 18-64?* This field is required.Enter a number

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C. What percent of your patients are older adults ages 65 and older?* This field is required.Enter a number

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3.Which of the following best describe the population your clinical practice serves (select all that apply)?* This field is required.Select all that apply

Low socioeconomic status (i.e. less than 200% of the Federal Poverty Line (FPL) - see https://aspe.hhs.gov/poverty-guidelines for more information)

Primarily Medicaid

Children's Health Insurance Program (CHIP)

Primarily uninsured

"Majority Minority" (i.e. most of your patients are racial/ethnic minorities)

Designated as medically underserved

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4. Which of the following best describes your clinical practice's organizational structure?* This field is required.Select one

Private non-profit agency

Public non-profit agency

Federally Qualified Health Center (FQHC)

FQHC look-alike

For-profit agency

Other (please describe below)

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Please describe your clinical practice's organizational structure if you selected "Other."

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5. Which of the following best describes the geographic location of your clinical practice?* This field is required.Select one

Rural

Urban

Suburban

Other (please describe below)

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Please describe the geographic location of your clinical practice if you selected "Other."

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Is your clinical practice located in a Health Professionals Shortage Area (HPSA)*? (*HPSAs are designated by HRSA as having shortages of primary care, dental care, or mental health providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible) or facilities (e.g., federally qualified health centers, or state or federal prisons) Click https://data.hrsa.gov/tools/shortage-area/hpsa-find to find out if your practice is in an HPSA. )'*HPSAs are designated by HRSA as having shortages of primary care, dental care, or mental health providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible) or facilities (e.g., federally qualified health centers, or state or federal prisons) Click here [https://data.hrsa.gov/tools/shortage-area/hpsa-find] to find out if your practice is in an HPSA.

Yes

No

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1. The CHAMPS program addresses the U.S. Department of Health and Human Services (HHS) clinical priorities of opioid abuse, mental health, and childhood obesity.* This field is required.Please select one priority area of focus for your CHAMPS fellowship.

Opioid abuse

Mental health

Childhood obesity

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2. Please describe your interest in your selected priority area (i.e. opioid abuse, mental health, childhood obesity) and how you plan to address it as a CHAMPS fellow.* This field is required.(1,500 character limit)

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3. How will your participation in the CHAMPS program develop your leadership capacity in healthcare transformation as a primary care professional?* This field is required.(1,500 character limit)

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4. How will your participation in the CHAMPS program help increase integrated and coordinated care services within your clinical practice?* This field is required.(1,500 character limit)

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5. How will your participation in the CHAMPS program help improve the quality of care in your clinical practice?* This field is required.(1,500 character limit)

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6.How will your participation in the CHAMPS program help increase access to patient care in your clinical practice?* This field is required.(1,500 character limit)

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If accepted to the CHAMPS program, I understand that I must meet the following participation requirements:* This field is required.

Attend orientation (early- to mid-August)

Dedicate a minimum of five (5) hours per week to complete the program requirements (i.e., online learning modules, healthcare transformation project, monthly reporting, monthly virtual clinic visits, coaching sessions)

Attend monthly group learning sessions

Complete interim and final presentations of progress and lessons learned and sharing of helpful tools with other CHAMPS participants

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Applicant CV* This field is required.Please upload your CV

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Letter of support from a clinical supervisor* This field is required.Please upload the Morehouse School of Medicine CHAMPS Leadership Agreement [insert link to access document] signed by a designated signatory at your organization

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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By clicking SUBMIT, I attest that all information on this application is accurate to the best of my knowledge.