Oregon SEARCH Application

The Oregon SEARCH program is funded by U.S. Department of Health and Human Services, Health Resources and Services Administration and is designed to provide opportunities for primary care clinicians-in-training to work with low income/vulnerable populations. Opportunities are located throughout Oregon. Every effort will be made to accommodate an applicant’s preferences with available openings.

Personal Information

Name

Date of Birth

Race/Ethnicity

African American
Asian
Caucasion
Native American
Hispanic/Latino
Native Hawaiian
Other

Contact Information

Phone #

E-mail

Current Address

Address

City

State

Zip Code

Permanent Address (if different from above)

Address

City

State

Zip Code

Application Questions

Name and address of the academic institution in which you are currently enrolled:

Name/Phone#/Email of contact person (for placements) at your program:

Profession

MD/DO
NP
PA
DDS/DMD

What year are you in training?

Expected training completion date (month/year)

What languages other than English do you speak?

When do you wish to participate in t he Oregon SEARCH program?

Start Date

End Date

How long is your rotation?

Will you be receiving academic credit for this experienc?

Yes
No

Does your academic institution/residency program cover your malpractice insurance during ‘away’ rotations/experiences?

Yes
No

Why do you wish to participate in the Oregon SEARCH program?

Do you have a preference as to site/population/location? If more than one, please prioritize.

Are you currently a National Health Service Corps Scholar?

Yes
No

Please write a short paragraph about yourself, your past experience, prior employment, volunteer experiences, etc.

Verification: