Chief Resident Application Form

Name:*

First Last

Preferred first name/nickname (as you would like it on your badge should you be accepted to the program):

Degree(s) earned (e.g., MD, MPH):*

Institutional/work email:*

Personal email:*

Please include an additional (i.e., non-institutional) email address you may be reached at.

Preferred email for CRIT communications:*

Cell phone/personal telephone:*

Residency Program Information

Residency program name:*

Residency program mailing address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Residency program medical school affiliation, if any:*

Write N/A if there is none.

Residency program hospital affiliation, if any:*

Write N/A if there is none.

Chief resident specialty (i.e., internal medicine, family medicine, other - please explain)*

Is your chief residency an additional resident year?*

Yes
No

Total number of residents in your residency program:

Percentage of time teaching:

Has your residency program participated in CRIT before?*

Mailing Address

Same as residency program address above?*

Yes
No

Mailing address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Faculty Mentor and Program Director Information

Faculty mentor name:*

Faculty mentor email:*

Is your faculty mentor applying to attend CRIT with you?*

Yes
No

Is your faculty mentor also your program director?*

Yes
No

Residency program director name:

Note: if you have already provided the residency program director's information above, you may leave these fields blank.

Residency program director email:

Other Information

Gender Identity*

If you selected "Prefer to self describe," please specify here:

Pronouns

If you selected "Prefer to self describe," please specify here:

Race/Ethnicity:*

Black or African American
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Other

Select all that apply.

Please describe "other":

Have you ever visited the following in a professional context? (Check all that apply.)

A mutual help or 12-step program (e.g., AA, NA, Learn to Cope)
A substance use treatment facility only (e.g., detox, methadone maintenance)
A harm reduction program (e.g., syringe service, naloxone distribution)

Preferred T-shirt size (should you be accepted to the program):*

What are your plans upon completion of your chief residency?*

Fellowship
Clinician Educator
Research
Full-time Clinical Practice
Academic Medical Center Practice
Private Practice
Other

Select all that apply.

If you selected "Fellowship," please specify here:

Please describe "other":

How did you hear about the CRIT Program?*

Previous CRIT Program attendee
Faculty at my institution
Brochure or postcard advertising the program
Internet search
Email from the program
Other (describe below)

Please describe "other":

Please specify:

Application Essay & Letters

Please provide a statement of 500 words or less describing your motivation and goals for participating in the CRIT Program. Discuss your interest in addiction medicine and how you plan to share the knowledge and skills gained at CRIT with your residency during your chief year. We also ask that all participants develop a substance use teaching project - if you know what you would like your project to focus on, please include this here. Copy-paste this into the box below.*

Please provide a letter of support from your residency program director that includes a statement of the expected percentage of your time that will be spent teaching during your chief resident year.

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

If you don't have this ready at the time of application submission please have it emailed to Jules Canfield at jules.canfield@bmc.org prior to the application deadline.

Please provide a letter of support from a faculty mentor who will support the integration of addiction medicine into your institution's curriculum. Note: if your residency director is also your mentor, only one letter is required.

Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

If you don't have this ready at the time of application submission please have it emailed to Jules Canfield at jules.canfield@bmc.org prior to the application deadline.

Curriculum Vitae

Please upload your curriculum vitae (CV) as a PDF here.*

Accepted file types: pdf, Max. file size: 100 MB.

25th Annual Chief Resident Immersion Training (CRIT) Program in Addiction Medicine: CHIEF RESIDENT Application

Residency Program Information

Mailing Address

Faculty Mentor and Program Director Information

Other Information

Application Essay & Letters

Curriculum Vitae