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  • Minority Clinical Fellowship Program Sponsor Registration

     

    Institution  
    Street Address  
    Address 2  
    City  
    State     
    Zip  
    Contact Name  
    Phone  
    E-mail  

    Number of HIV Patients    
      % Female  
      % Asian  
      % Black/African-American  
      % Hispanic or Latin  
      % Native American or Alaskan Native  
      % White/Caucasian  
      % Other  
    HIV subpopulations of interest:
         
     

    About how many HIV patients might the clinical fellow be managing?  
    Will fellows have access to HIV inpatient clinical care?
         
    How many fellows can your institution support?  
    Assuming funding from HIVMA to cover salary/benefits, will your institution be able to offer the candidate an employee benefits package?
         
    Will fellows have access to other HIV medical education opportunities such as lectures, case studies, etc? 
         
    Does your institution have links to other clinics/programs at which candidates may spend up to 2 months of their fellowship? 
         
    How many HIV physicians are on staff at this institution?   
    How many HIV sub-specialists are on staff?  
    Obstetrics/Gynecology  
    Gastroenterology  
    Hematology-Oncology  

    Does your institution already have an HIV Training Program? 

            

    Is this program part of an Infectious Diseases training program? 

         

    If no, please describe.

     


    Has the fellowship been approved by your institution? 

           

    Are you able to accommodate a clinical fellow(s) for 1 year beginning July 1? 

         
    What is the full name of the proposed mentor for this program (if known)?  
    What is his/her title?  

     

     

 

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