First name *
Last name *
General Information
Education
Will you be enrolled in a degree-granting program through April 2028? *
— select —
Yes
No
What year in your degree program will you be during the 2027-2028 academic year? *
Discipline of Study *
What type of Fellowship are you applying for? *
— select —
Junior
Senior
Do you plan on applying for an IRB at any point in the Fellowship year (i.e: starting a new IRB, amending a current IRB, applying for a waiver)? *
— select —
Yes
No
If yes, please explain. *
During your project year from May 2027 - May 2028, please describe any anticipated scheduling conflicts, including away rotations, fieldwork, travel, or graduation. *
Mentors
Please list your proposed Academic Mentor. Include contact information such as telephone number and/or email address. *
Please list your proposed Site Mentor. Include contact information such as telephone number and/or email address. *
Proposed Community Partner
Please list your proposed community partner(s). If a community agency has not yet been identified, please type TBD and a one-liner for your reason. *
Project Information
Please note that citations are not included in the word count.
1. Please describe the social problem (ecosystem and root causes) and target population you wish to impact with your proposed community service project, including demographic information. This answer should be the same for all project partners. *
Word limit: 150.
Citations (type N/A if not applicable) *
2. Describe the community need for your project and how your project will address an unmet health need. This answer should be the same for all project partners. *
Word limit: 150.
Citations (type N/A if not applicable) *
3. Describe a future where the problem your proposed project addresses is absent. Include your vision for systems changes and impacts on non-medical drivers of health. This answer should be the same for all project partners. *
Word limit: 150.
4. Please describe your proposed community service project, including project goals, the actions you will take to meet these goals, and anticipated outputs. This answer should be the same for all project partners. *
Word limit: 200.
5. How do you hope these actions will drive social impact for the target population identified in question 1? This answer should be the same for all project partners. *
Word limit: 150.
Citations (type N/A if not applicable) *
6. Describe the avenues you will explore to sustain the project beyond your time as a Fellow. How would you identify individuals to carry on the legacy of your work? How would you involve your community partner in developing materials or practices they could continue using after your Fellowship ends? This answer should be the same for all project partners. *
Word limit: 100.
7. How will you evaluate this project to determine its impact? This answer should be the same for all project partners. *
Word limit: 150.
8. How will your proposed project innovate current efforts that address these social problems? This answer should be the same for all project partners. *
Word limit: 150.
Citations (type N/A if not applicable) *
Personal and Professional Information
9. What draws you to this specific project? Describe experiences, interests, or connections that would inform your contribution. These may come from coursework, employment, volunteering, family or community life, or lived experience. Share only personal information you feel comfortable sharing. This answer should be different for all project partners. *
Word limit: 250.
10. Describe a time you worked with others whose priorities or perspectives differed from yours. How did you listen, respond to feedback, and contribute to a shared outcome? What would you bring from that experience to working with your community partner and community members? This answer should be different for all project partners. *
Word limit: 200.
Patient Navigation Program (PNP)
If your project involves resource navigation, are you applying for the Patient Navigation Program (PNP)? This includes new projects or Legacy projects. *
If I have selected yes to the above, I understand that I will be applying to be an ASF Patient Navigation Program (PNP) Fellow. If I am chosen to serve as an ASF PNP Fellow, I will commit to the additional following tasks, which would count for service hours (please check each box below).
— select —
Yes
No
Attend 4-5 additional in person didactic sessions in Houston *
Use the ASF resource database to focus on resource navigation in my project *
Submit monthly data tracking including numbers of referrals by category and status of referrals *
Complete additional evaluation surveys, focus groups, and check-in emails *
Attend periodic group Zoom check-ins *
Answer an additional question on the monthly report about my patient navigation experience *
I acknowledge that my role as a PNP Fellow will involve engaging in one-on-one conversations with patients to identify their non medical drivers of health needs, connecting them with appropriate community resources through warm handoffs, and conducting follow-up to help ensure successful connections and facilitate closed-loop referrals. *
“Save & continue later” gives you a private link to finish your application any time before the deadline.