I
understand that if my application
is accepted for the Montana NHSC SEARCH Program, financial
assistance may be available to assist with my travel
and living expenses. The Montana NHSC SEARCH
Program determines the amount, which is based on a
four-week time period as well as the distance traveled
to Montana. [The availability of rotations in
Montana depends on the number of available preceptors
and the amount of funding our state receives from the
NHSC.] |
____ Yes ____
No |
If I participate
in the NHSC SEARCH Program, I will submit a
one-page essay regarding community service performed
while in my preceptorship community. |
____ Yes ____
No |
If I participate
in the NHSC SEARCH Program, I accept the responsibility
of immediately notifying the Montana NHSC SEARCH Program
of the following: (1) changes in plans,
(2) early termination of the rotation, and (3)
problems during the community rotation. |
____ Yes ____
No |
At the
conclusion of the NHSC SEARCH Program rotation, I
agree to submit my evaluation of the experience. [Evaluation
form is provided by the Montana NHSC SEARCH Program
and mailed to the preceptor along with your NHSC funds
approximately two weeks prior to your arrival at the
rotation site.] |
____ Yes ____
No |
I agree
to respond to an annual questionnaire as
a means of determining the impact of the NHSC SEARCH
Program on specialty choice and practice location. |
____ Yes ____
No |
I understand
that for my application to be complete, it is my
responsibility to arrange for malpractice
insurance through my school. I have
attached a copy of that proof of coverage to
this application (a letter from a school official indicating
coverage will suffice). [It will be necessary
for you to be covered by malpractice insurance during
this experience. The Montana NHSC SEARCH Program
does NOT provide this malpractice
insurance coverage.] |
____ Yes ____
No |