and Control Branch to enhance diabetes prevention and control, we agree to do diabetes activities. It should also describe other diabetes programs and …
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NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES DIABETES PREVENTION AND CONTROL BRANCH APPLICATION FOR ENROLLMENT IN THE HUGH YOUNG MEMORIAL SCHOLARSHIP PROGRAM ECU BRODY SCHOOL OF MEDICINE DIABETES EDUCATION FELLOWSHIP Name: ________________________________________________________________________________________ Agency: _______________________________________________________________________________________ Phone: __________________________Fax: _________________________E-Mail: ___________________________ Home Address ________________________________________________________________________________ City __________________________________ State ________ Zip________ North Carolina Part Time Contract Service Date of Employment: _________ Type of Employment: Full Time Fellowship Dates Requested: Sept 22-26, 2008 February 23-27, 2009 May 18-22, 2009 Non Smoking Smoking Accommodations not required Shared Accommodations Only: If You Are Not Employed In A Local Health Department, Is Your Organization A Non-Profit One? EXPERIENCE indicate all that apply: Clinic Generalized Adult Health Home Health Maternity Diabetes Related Other Dates from/to ____________ ____________
____________ ____________ ____________ ____________ Clinic Family Planning Child Health TB School Health WIC Health Promotion Dates from/to ____________ ____________ ____________ ____________ ____________ ____________ II II II III Yes No
INDICATE YOUR APPROPRIATE CLASSIFICATIONs: I Registered Nurse staff nurse — clinic nurse Nursing Supervisor Public Health Nurse I II III Physician Assistant I Nurse Practitioner I Registered Dietitian II Health Educator I II III Nutritionist I Pharmacist Certified Diabetes Educator Other Please describe _______________________ EDUCATION Diploma/Associate Degree Baccalaureate Master Other ie, NP, PA, etc Field/Degree _________________________ _________________________ _________________________ _________________________
Date Issued _________________ _________________ _________________ _________________
DISCRIPTION DETAILING CURRENT RESPONSIBILITIES RELATED TO DIABETES PREVENTION CONTROL
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_______________________________________________________________________________________________ _______________________________________________________________________________________________ De Vernon OR FAX TO: 919-870-4801 PLEASE MAIL TO: NC Diabetes Prevention and Control Branch Main Office: 919-707-5340 1915 Mail Service Center Raleigh, North Carolina 27699-1915 MUST BE RECEIVED 6 WEEKS PRIOR TO FELLOWSHIP
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ASSURANCE FOR PARTICIPATION North Carolina Diabetes Prevention and Control Branch Hugh Young Memorial Scholarship Program East Carolina University Brody School of Medicine Clinical Fellowship in Diabetes
As a Local Health Department or other non-profit organization participating with the NC Diabetes Prevention and Control Branch to enhance diabetes prevention and control, we agree to do the following activities: 1 To send a nurse, nutritionist RD, RD-eligible or LDN, pharmacist or health educator team or individual to the East Carolina University Brody School of Medicine Clinical Fellowship in diabetes 2 To designate one of the above staff as Lead Diabetes Educator This person will serve as a liaison to the Diabetes Prevention and Control Branch 3 To provide
diabetes education and/or treatment to clients______ hours per week or month please circle one 4 To provide a brief written description of new diabetes activities developed or conducted after attending the Clinical Fellowship This description should identify resources, including staff, dedicated to these diabetes activities It should also describe other diabetes programs and resources available in the county and any partnerships developed 5 To arrange for staff attending training to conduct an in-service program for other staff within the organization or professionals in the community within six months after returning from the East Carolina University Fellowship 6 To advocate for and support all diabetes efforts initiated by the Lead Diabetes Educator or team The following staff will attend the East Carolina University Brody School of Medicine Clinical Fellowship:
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Health Director/Supervisor if non-health department Signature Health Directors/
Supervisors Name: _____________________________________________________ Mailing Address: ______________________________________________________________________ City: __________________________________ State: ____ Zip: __________ Courier Code________ NC
Telephone No: ________________________________________________________________________ Fax No: _________________________ Email Address: _______________________________________ 2 of 2 pages
Source:ncdiabetes.org
