Montana Family Practice Residency
Billings, Montana
Montana
National Health Service Corps
SEARCH Program

2004-2005 Application Packet

National Health Service Corps Logo

Montana State Seal
Montana Primary Care Office

Please address questions or comments to:
Paula Clifford
Montana NHSC SEARCH Program
Montana Family Practice Residency
123 S. 27th Street
Billings, MT  59101
406-247-3291
Fax:  406-651-6418
paulac@ycchd.org

For more information about the Montana NHSC Search Program,
visit the Montana Primary Care Office Website at: 
http://www.mtsearch.info

          The Montana NHSC Search program is funded by the National Health Service Corps,
          Administered by the Montana Primary Care Office, and Operated by the Montana Family
          Practice Residency.
MONTANA SEARCH PROGRAM REQUIREMENTS
and PLACEMENT PROCESS
  1. Students who have completed at least the first year of their program and primary care residents who are interested in rural/ underserved health care are invited to apply.
  2. Preference is given to: NHSC Scholars; WWAMI medical students; Montana State University (MSU) nurse practitioner students; physician assistant students at Rocky Mountain College; primary care residents affiliated with the Montana Family Practice Residency Program or residency programs at the University of Washington.
  3. Applicants are required to provide proof that malpractice insurance coverage for the rotation is provided through their professional school or clinic. A brief letter from an Administrative Officer (e.g., Dean of Students) is sufficient.
  4. Medical students and physician assistant students do not require a license to practice in Montana for this program; however, resident physicians and nurse practitioner students DO require a license to practice in Montana for this program.
  5. Students and residents who are placed will be matched to a primary care preceptor in a Health Professional Shortage Area (HPSA) or in a rural or urban Medically Underserved Area (MUA). Every attempt will be made to honor preferences for primary care specialty and rural/urban underserved location.
  6. Once notified of their match with a preceptor, the student or resident must contact the preceptor (or a representative) to make further arrangements for the rotation, such as firm dates and housing. The Montana NHSC SEARCH program is available for assistance should these arrangements become difficult.
  7. Students and residents who are placed are required to participate in a service-linked community activity and at the end of the rotation to provide a one-page essay describing the experience.
  8. Participants in the NHSC SEARCH Program accept the responsibility of immediately notifying the Montana NHSC SEARCH program of any of the following: (a) any change in rotation plans; (b) early termination of the rotation; and (c) problems or concerns during the rotation.
  9. Program participants are required to complete an evaluation form (which is provided) at the end of their experience and return it to the Montana NHSC SEARCH Program.
  10. Students and residents must agree to participate in a long-term "tracking" program and return all brief requests for updates and additional information
WHO IS ELIGIBLE?
Eligible health professional fields include:  allopathic and osteopathic medicine; general internal medicine; general pediatrics; obstetrics/gynecology; primary care physicians; dentists and dental hygienists; clinical psychology; clinical social work; psychiatric nursing; marriage and family therapy; family/primary care nurse practitioners; primary care physician assistants; and certified nurse-midwives. 

Name: ________________________________________________________________________
               First                                        MI                 Last                                                        Suffix
            
Social Security Number __________________    Ethnicity (optional) ______________________

Mailing address while attending school: _________________________________________________

     ______________________________________________________________________________

    _______________________________________________________________________________ 

Contact Phone: ______________  Until: ____________________  Fax [not required]: _______________

E-mail Address: ___________________________________________


Have you previously participated in the Montana NHSC SEACH Programs? ___ Yes ___ No

If Yes, Where: ______________________________________________________________

            When: ______________________________________________________________

            Name of Preceptor:____________________________________________________

            Name at time of Preceptorship: __________________________________________

Are you a National Health Service Corps Scholar? ___ Yes ___ No
         [The NHSC Scholarship program and the SEARCH program are two different programs.]


The NHSC SEARCH Program needs to follow your progress through your professional education to see if the SEARCH Program has had an impact on your choice of specialty or practice site.  You will very likely change your address several times in the next few years, so please give the name, address and phone number of an individual who will know your location for the next 10 years. [Preferably someone not living with you.)

Name: ___________________________________________________________________

Street/PO Box:  ____________________________________________________________

Apartment: ________________________

 City/Town: _________________________________  State:_________  Zip: ___________

Contact Phone: ___________________


Name of School/Residency Program: __________________________________________

Name of Advisor or School Contact: ___________________________________________

Advisor or School Contact's Address: __________________________________________

Street/PO Box: ____________________________________________________________

Apartment: ___________________

 City/Town: ______________________________  State:__________  Zip: ____________

Contact Phone: __________________   Email Address: ____________________________


Current Year in Professional School or Residency Program:

                  ____   Year 01
                  ____   Year 02
                  ____   Year 03
                  ____   Year 04

Anticipated Graducation Date: _________________________


Birth Place: _____________________________________________________________

High School Attended: ____________________________________________________

Enrollment [if known]   ____ <100   ___ 100-600    ___601-1200    ___1201-1800     ____>1800

 City/Town: _______________________________  State:__________  Zip:__________

State of Legal Residence: __________________

Rank the type of community in which you plan to practice (1=Highest & 5=Lowest):

Rural ____       Small Town ____       Suburban ____     Inner-city ____     City ____

Rank your specialty preference in your rotation/internship (1-first choice):

Family Practice ____      Internal Medicine ____       Pediatrics Obstetrics& Gynecology

Marriage & Family Counseling ____      Other Mental Health ____      Dental ____

____ Other [Please Specify] _________________________________________________


What dates do you have available for this educational experience?

 ____ Any time (May 15th through August 31st)

____ Specify the 4-week span of time you would prefer. ___________________________________


Why are you interested in a Montana rotation?

 

 

 

 

 

 

 

Do you have family or available housing in Montana? ____ Yes      ____No
[Not a requirement, but helpful!]

What are your preferences, priorities, and goals for this educational experience?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agreement of Terms

*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

Signature: ________________________________________________ Date: _____________________

IMPORTANT - Licensure Information:  Medical students and Physician Assistant students do not require a license to practice in Montana for this  program.  Physicians in Residency training and Nurse Practitioner studentsDO require a license to practice in Montana for this program. If the necessary license application or information has not been enclosed, please contact the Montana NHSC SEARCH Program immediately.

Please Mail Signed Application to:

Paula Clifford
SEARCH Program Administrator
123 S. 27th Street, Suite B
Billings, MT 59101

National Health Service Corps SEARCH Program.  This project is funded by contract/order number 03-0164P from HRSA of the U.S. Department of Public Health and Human Services and Montana Department of Public Health and Human Services, Primary Care Office. The contents herein do not necessarily reflect the official views and policies of the U.S. Department of Health and Human Services or the Montana Department of Public Health and Human Services