Fellow Application

Name:*

First Last

Preferred first name/nickname:*

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

Institutional/work email:*

Personal email:*

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

Preferred email for FIT communications:*

Cell phone:*

Fellowship Program Address

Institution*

Specialty (e.g., infectious disease, adolescent, GI, etc.):*

Fellowship program address:*

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

Fellowship program medical school affiliation, if any:*

Write N/A if there is none.

Fellowship program hospital affiliation, if any:*

Write N/A if there is none.

Faculty mentor name:*

Faculty mentor email:*

Is your faculty mentor the same as your fellowship program director?*

Yes
No

Fellowship program director name:

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

Fellowship program director email:

Mailing Address

Same as above?*

Yes
No

Mailing address:

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

Other Information

Gender Identity*

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

Pronouns

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

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":

Are you a member of an underrepresented group (URG) in biomedical, clinical, behavioral or social science? are unsure if you would be considered as being a part of an Underrepresented Group, see below link for a full list. This is not an exhaustive list and we are continuously working to update it accordingly to be representative of all people in underrepresented groups.

Yes
No

https://diversity.nih.gov/about-us/population-underrepresented

Please specify

Individual from racial and ethnic groups that have been shown by the National Science Foundation to be underrepresented in health-related sciences on a national basis
Individual with disabilities, who are defined as those with a physical or mental impairment that substantially limits one or more major life activities
Individual from disadvantaged backgrounds (those who meet two or more of the disadvantaged background criteria listed on the above NIH website)
Prefer not to specify

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):*

Fellowship Information

Fellowship program name:*

What is the total length of your fellowship? (e.g., 2 year, 3 year, 4 year total)*

Which year of your fellowship will you be in as of April 2025?*

Please describe "other":

Percent of time available for research:*

What are your plans upon completion of your fellowship? (Check any or all that apply)*

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

Please describe "other":

How did you hear about the FIT Program?*

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

Please describe "other":

Please specify:

Application Essays

Please provide a personal statement of 500 words or less describing your motivation and goals for participating in the FIT Program. Relate your interest in addiction medicine and research to your previous training, fellowship plans, your career aspirations, and how you will apply the knowledge gained at the FIT Program. Copy-paste this into the box below.*

Please include a description of no more than 300 words describing a research project idea that incorporates addiction medicine and that you could undertake during your fellowship. This description should include the project idea’s aims, research question, methods and potential implications. Please upload your statement with NAME and DATE in the header as a PDF here.*

Max. file size: 100 MB.

Curriculum Vitae

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

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

14th Annual Fellow Immersion Training (FIT) Program: Fellow Application

Fellowship Program Address

Mailing Address

Other Information

Fellowship Information

Application Essays

Curriculum Vitae