The Student/Resident Experiences and Rotation in Community Health (SEARCH) Program is an opportunity to prepare for the new direction in health care — the provision of community-based, culturally competent primary care by interdisciplinary teams of health care professionals. Through this experience participants will see the rewards of working in collaboration with other primary care health professionals, in underserved areas of the state. The National Health Service Corps (NHSC) has developed the SEARCH program based on the philosophy that training primary care providers in collaborative care, cultural competence and community oriented primary care is the key to a different future in health care — more integrated, comprehensive and accessible primary care for everyone in need. For up to date information on the current SEARCH program please see our Quarterly Newsletter on this website. Thank you. Justine Ceserano, Director NJ SEARCH Program PHONE (609)689-9930 x 17, FAX (609)689-9941.

A. Personal Information

Name:    Current Street Address:    City:    State:    Zip Code:    Home Phone:    Work Phone:    E-mail:    Permanent Street Address:    City:    State:    Zip Code:    Date of Birth (mm/dd/yy):    How would you prefer your mail sent? Current Permanent

B. Educational Information

School/Dept.:    Street Address:    City:    State:    Zip Code:    Academic Standing:  Student Resident MD Resident DO

Degree Sought:    N.P. P.A. M.S.W. D.O. M.D. Other Year in program:    First Year Second Year Third Year Fourth Year Date of Expected Graduation:    Jan Feb March April May June July Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Your Program/Track:    Family/FP I.M. Peds Adult OB/GYN Counseling Other (Medical Students, see question below)

* Specific Clinical Rotation, if any, during    which you will be doing the fellowship:    None Family/FP I.M. Peds Adult OB/GYN Counseling Other

C. Other Information

Number of weeks you wish to be placed:    Preferred Start Date:    Jan Feb March April May June July Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Preferred End Date:    Jan Feb March April May June July Aug Sept Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Days of the week you are available:  MonTueWedThursFri       Number of days per week you wish to be placed:    1 2 3 4 5 Are you receiving a NHSC scholarship?   Yes No Do you speak spanish?    Yes No Describe Fluency:      Other languages?      Do you require housing?    Yes No * Why do you wish to participate in the SEARCH program?   * What relevant experience do you bring (resume optional)?

(Race and Ethnicity information is VOLUNTARY and will only be used in the aggregate for the tracking of primary care professionals.)

* How would you describe yourself?    White, not of Hispanic origin Black or African Amer., not of Hisp. Origin Hispanic Asian or Pacific Islander Native Amer. or Alaskan Native Other