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April 7, 2015
Dear Prospective Fellow:
Physicians for Reproductive Health is seeking the next cohort of extraordinary physician-leaders to
become Fellows of the Leadership Training Academy Class of 2016.
The Leadership Training Academy is designed for physicians who are willing and able to become active
ambassadors for comprehensive reproductive health care.
The goal of the Academy is to cultivate and support emerging physician-leaders in reproductive and
sexual health advocacy. Expert instructors in leadership development, communications, policy, and
medical education will help the Fellows develop and utilize the necessary skills to become effective,
lifelong advocates for reproductive health.
Academy Fellows will learn firsthand how to educate policymakers, the medical community, and the
public about preserving and expanding access to reproductive and sexual health care for all women
and men. You will have opportunities to discover, work, travel, and serve alongside outstanding
physician-leaders from a variety of specialties and from across the United States. You will improve your
presentation skills, appear in the media, hone your leadership abilities, collaborate with colleague
organizations, talk with legislators, and reach your peers.
Applications are open to:
1. Physicians entering their final year of the Fellowship in Family Planning.
2. Physicians who are entering the TEACH Leadership Fellowship or RHAP Reproductive Health
Care and Advocacy Fellowship.
3. Physicians who are alumni of the Fellowship in Family Planning.
4. Physicians who are Directors of Ryan Residency programs.
5. Practicing physicians of any specialty, with priority considered for those who practice in leastaccess states. These participants are required to pay a registration fee of $500 (which covers
training materials and most meals) and are responsible for covering their own expenses for
travel and lodging.
The Academy program is available at no cost to current participants and alumni of the Fellowship in
Family Planning, participants in the TEACH or RHAP Fellowships, and Ryan Residency Directors through
funds from a categorical grant.
The Academy has scholarship funds to cover the expenses of one or more applicants who are not
current participants of the Fellowship in Family Planning, FPF alumni, TEACH or RHAP fellows, or Ryan
Residency Directors. To apply for the scholarship, fill out the appropriate section in this application.
Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
We have limited spaces available for the Class of 2016.
The deadline for applications is Friday, June 5, 2015.
Telephone interviews will be scheduled when complete applications are received.
If you have questions, please contact Libby Benedict at [email protected] or 415.990.6502.
Thank you for your interest in the Leadership Training Academy!
Sincerely,
Libby Benedict, MPA
Director, Leadership Training Academy
Jodi Magee, MSW
President/CEO
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Requirements
In order for your Academy application to be complete, you are required to agree to the following:
1.
Be committed to learning the skills and developing the attributes of a model leader who is willing
and able to be active on reproductive health issues
2.
Have the full support of your direct supervisor to participate in the program, including spending
time away to attend training sessions and time to participate in monthly webinars
3.
Be available to attend three in-person meetings:
i.
ii.
iii.
Sunday evening, October 18 – Thursday, October 22, 2015 in Washington, DC
Monday evening, February 22 – Friday, February, 26, 2016 in New York, NY
Thursday, May 12, 2016, in Washington, DC (prior to ACOG Annual Clinical Meeting)
4.
Participate in six monthly 90-minute webinars, scheduled for the second Tuesday or Thursday of
each month at 7:00 p.m. EST, from November 2015 through June 2016
5.
Independently seek and identify for Physicians at least one advocacy activity in media, policy, or
medical education systems work; or with Physicians staff (or coalition partners’) assistance,
participate in at least one opportunity from each category
6.
Attend at least one state and one federal advocacy event organized by Physicians or our
colleague organizations
7.
Respond in a timely manner to requests from Physicians to speak to the media and/or write
letters to the editor, op-eds, or blog posts
8.
Remain engaged in the Academy as a mentor and potential faculty; actively participate in and
contribute to the LTA Talk listserv
9.
For those who are not current participants or alums of the Family Planning Fellowship, current
participants of the TEACH or RHAP fellowships, or Ryan Residency Directors: Agree to pay a
registration fee of $500 (which includes training materials and meals) and be responsible for
covering your own expenses for travel and lodging
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Application Process & Instructions
Space is limited. The deadline for applications is Friday, June 5, 2015.
Application Form
You must have Adobe Reader installed on your computer in order to complete the PDF application form.
If you do not have it installed, you can download it for free at http://get.adobe.com/reader.
To apply to the Leadership Training Academy, please complete the first four sections of the application
form:
Section I: Applicant Information
Section II: Background and Experience
Section III: Participant Agreement
Section IV: References
Section V: the scholarship application, is optional
Submission Requirements
1. Send an email to Libby Benedict at [email protected] with the following documents as attachments:
i.
ii.
Your completed PDF application form
Your curriculum vitae (CV): Your CV must be submitted in Word or PDF format and must be saved
as follows: Last Name_First Name CV
2. Ensure that your two letters of recommendation are sent by email to Libby Benedict at [email protected].
See section IV for further instructions. If you are applying for the scholarship, an additional letter of
recommendation must also be emailed to [email protected]. See section V.
You will not be considered an applicant for the Leadership Training Academy until all required documents
are received (completed application form, curriculum vitae, and two letters of recommendation). You will
not be considered for the scholarship unless you have also completed Section V of the application and we
receive your additional letter of recommendation.
Once completed applications are received, all applicants will be contacted for a phone interview. We will
contact you after your submission at which time we may also ask you to complete a Conflict of Interest
form.
All applicants will be informed about the status of their application via email no later than July 16, 2015.
If you have any questions about the Academy program, please contact:
Libby Benedict
Director, Leadership Training Academy
Physicians for Reproductive Health
415.990.6502
[email protected]
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Section I: Applicant Information
Please check the box that applies to you:
Family Planning
Fellow
Name
FPF Alumni
Ryan Residency
Director
Last
TEACH or RHAP
Fellow
Other Physician
First
Degree(s)
Title
Specialty
Institution and Department
Primary
Work Address
Street Address
City
State / Province
- State -
Country
Work Phone
9 Digit Zip Code
(Look up at usps.com)
Work Cell Phone
Work Email
Home Address
Street Address
City
State / Province
- State -
Country
Home Phone
9 Digit Zip Code
(Look up at usps.com)
Cell Phone
Preferred or Primary Email
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Fellowship Director or Direct Supervisor
Name
Title
Email
Phone Number
Choose from the following options to
describe your practice setting (check
all that apply):
University/Academic Hospital
Private Practice
Dedicated FP/Abortion Clinic
Other (please explain)
Community Health Center
Are you registered to vote in the
United States?
If YES, Where?
YES
NO
- State -
Legislators and Districts (If you do not know yours, look them up at http://www.votesmart.org)
State Senator and District
State Representative and District
Senior U.S. Senator
Junior U.S. Senator
U.S. Representative and District
The following information is for grant-reporting and program-customization purposes only. All
information received will remain private and confidential.
Gender
Race/Ethnicity
Date of Birth
Place of Birth
Physical or Other Disability
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Section II: Background and Experience
Please limit your answers to ƋuestionƐ 1 - 5 to 300 words.
1. Please describe your career plans and aspirations.
2. How would you describe physician leadership?
3. How have you demonstrated leadership in your own work?
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
4. Why do you want to participate in the Leadership Training Academy?
5. How do you expect this training to help you become a leader in comprehensive reproductive and
sexual health and rights? What skills do you hope to gain?
Describe a situation when you, as a member of a medical team, contributed to a success of that team,
and how.
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Describe a situation in which your medical team was unsuccessful.
Describe the role you played.
Faced again with the unsuccessful situation you described above, how would you deal with it
differently?
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Which of the following four options best describes your experience and confidence with
respect to speaking with the media? Choose 1 box only.
Inexperienced and no confidence
Inexperienced and some confidence
Some experience and some confidence
Experienced and confident
For each item below, select a number between 1 and 4 from the drop down menu to
indicate your level of experience in that area, with 1 denoting “no experience” and 4
denoting “considerable experience”
Community organizing
- Select -
Letters to the editor, op-eds, blogs
- Select -
Public speaking
- Select -
Teaching
- Select -
Testifying, lobbying, advocating for a cause
- Select -
U.S. medical education systems
- Select -
List any leadership positions you have held in the following areas, the year(s) you held the
position, and the name of the organization with which you held each position:
Within your own institution
(e.g. Residency Director,
Clerkship Director, etc.)
Development:
Fundraising or membership
recruitment
Communications:
Public relations, nonmedical
publications and/or websites,
broadcast media
Public policy, advocacy, or
community organizing:
Local, state, or federal
Medical Associations,
Societies, or accrediting
bodies
Research: Journals,
research teams
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Indicate skill level in language/s other than English:
Spanish
(list others below)
- Select - Select - Select - Select -
The following information is for grant-reporting and program-customization (internal)
purposes only, and participation is voluntary. All information received will remain private
and confidential.
Do you currently provide abortion services
(surgical or medication)?
If you are an abortion provider, do you work at
multiple sites or practices?
Yes
No
Yes
No
Do you provide surgical abortion care?
Yes
No
Do you provide medication abortion?
Yes
No
Up to how many weeks are you trained to
provide?
Up to how many weeks do you currently provide?
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Section III: Participant Agreement
Please mark the box next to each requirement.
I understand that successful completion of the Academy program is dependent upon active
participation throughout the program year, starting October 18, 2015, through June 2016.
I have the full support of my direct supervisor to participate in the Academy, including time away to
attend sessions and participate in monthly webinars.
If selected to participate in the Leadership Training Academy, I commit to:
Serving as an active participant in the Academy and fulfilling my obligations to the program for the
complete scheduled period (October 2015 through June 2016).
Completing and returning periodic evaluations to measure skills acquired and used, including an
evaluation one year after program completion.
Completing the Physicians Conflict of Interest Forms and updating them as needed.
Mark this box only if you are NOT a Family Planning, TEACH or RHAP Fellow, alum of the
Fellowship in Family Planning, or Ryan Residency Director:
I agree to cover my own expenses related to the program, including a registration fee of $500,
travel, and lodging.
Agreement and Signature
In submitting this application to the Leadership Training Academy, I attest to the accuracy of the
information I have provided and acknowledge that the information is subject to verification by Physicians
for Reproductive Health.
Please indicate your agreement with the statement above by typing your full name in the
following field:
Full Name
Date
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Section IV: References
Two letters of recommendation are required. For current Family Planning and TEACH or RHAP Fellows, one
letter must be from your Fellowship Director. For other physicians, a letter of recommendation from your
direct supervisor is required.
Letters of recommendation should be submitted in Word or PDF format and must be saved as follows
(referring to the name of the applicant): Last Name_First Name Recommendation
Please have your two letters emailed separately or as a group to Libby Benedict at [email protected].
Your application will not be considered until both letters of recommendation are received.
Please enter the following information for the individuals from whom you are requesting letters of
recommendation:
Reference 1
Name
Title
Relationship
Email
Telephone
Reference 2
Name
Title
Relationship
Email
Telephone
SCHOLARSHIP APPLICATION NEXT PAGE
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Section V (optional): Scholarship Application
The Leadership Training Academy may have scholarship funds available for applicants who are not
current participants or alumni of the Fellowship in Family Planning, current participants of the TEACH or
RHAP fellowships, or Ryan Residency Directors. The scholarship will cover all program expenses.
Please answer the following 3 questions in order to be considered for the scholarship.
In Section II, we asked you about the leadership positions you have held. Please describe how you
have used your leadership skills to make a difference using your position(s). How have your efforts
resulted in significant change? Please limit to 100 words.
How do you intend to contribute to the debate over reproductive and sexual health? Please limit to
100 words.
Why should you receive this scholarship? Please limit to 200 words.
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Physicians for Reproductive Health
Leadership Training Academy
Application Form, Class of 2016
Scholarship Reference
In Section IV, we asked you for two letters of recommendation. To be considered for the scholarship,
you must submit a letter of recommendation from a third person. This individual must be a physician.
S/he may be a professor, supervisor, mentor, or another physician who has known you for a year or
more and can attest to your leadership skills. Please enter the information for your scholarship
reference here:
Scholarship Reference
Name
Title
Relationship
Email
Telephone
Letters of recommendation should be submitted in Word or PDF format and must be saved as follows
(referring to the name of the applicant): Last Name_First Name Recommendation
Your letter of recommendation must be emailed to Libby Benedict at [email protected].
Your application will not be considered until all letters of recommendation are received.
Agreement and Signature
In submitting this application for the Leadership Training Academy Scholarship, I attest to the accuracy
of the information I have provided and acknowledge that the information is subject to verification by
Physicians for Reproductive Health.
Please indicate your agreement with the statement above by typing your full name in the following
field:
Full Name
Date
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