Wisconsin Population Health Service Fellowship Program Placement Interest Form
Thank you for your interest in being a placement site for the Wisconsin Population Health Service Fellowship Program. Please complete the form below to be considered for as a placement site. The program matches Fellows to placement sites based on several considerations including, but not limited to: Fellow interest areas, opportunity for Fellow growth, opportunity for Fellows to meaningfully contribute and provide service to sites, and mentorship capacity. The information on this form will be used to inform Fellow and placement site matching and document document placement site interest.
Name: *
Your answer
Organization: *
Your answer
Email *
Your answer
Have you ever served as a Preceptor to a UW Population Health Service Fellow? *
Is so, when?
Your answer
Have you ever served as a mentor or preceptor other than for a UW Population Health Service Fellow? *
If so, please describe. *
Your answer
Please provide a brief overview of possible projects a Fellow might work on in your organization: *
Your answer
How do you believe a Fellow will benefit by working at your placement site? *
Your answer
What skills are you looking for in a Fellow? *
Your answer
A limited number of Fellows slots are funded by the Wisconsin Partnership Program each year. It is sometimes possible for the program to recruit additional fellows if we have additional funding to support them. Do you have the means to possibly contribute financially to supporting all or part of a fellow? *
Please share any other information that you would like prospective Fellows or the program to know about your interest in being a placement site.
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