Application for
“Gap Year” 2020-2021
Research Internship
Please type all answers on this application form and then ‘save’.
Information
Last Name: First Name:
Current Address: City: State: Zip:
Permanent Address: City: State: Zip:
Permanent Address Phone: Cell Phone: Email:
Date of Birth: Sex: Male Female Skype ID:
Current Status
Name of Undergraduate School:
Current College Level: Senior Post-Bacc (explain): ____________________________________________________
Graduation Date (mo/year):_____________________ Degree: B.A. B.S. Other ________________________
Major: 2nd Major:
Minor / Concentration: 2nd Minor / Concentration:
How many college-level statistics classes have you taken? None 1 2 3 >4
Do you have other statistics experience/expertise? (If yes, specify) No Yes: _________________________________
With which software/programing languages are you experienced: SPSS SAS Python R Other
GPA (cumulative): _____________ Do you have proficiency using EndNote? No Somewhat Yes
What graduate degree(s) do you ultimately plan to pursue: n/a MD Other (specify): ______________________
When is the first and last day you can work (month/day)? First: _____________________ Last:________________________
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What are your academic and/or clinical interests, and what do you hope to accomplish during this internship? (Please be as
specific as possible regarding your expectations and the types of experiences that you want to have this year.)
Please provide information about any past research experience. Please describe your specific role and responsibilities with these
research endeavors, and the time commitment that was involved. If you do not have research experience, you may share
information about other past experiences that you believe make you a competitive applicant for this research position.
For General Pediatrics Internship applicants only: 2 Questions - 1) Are you proficient in Zotero or NVivo? 2) Please describe
past experience working or volunteering with the undeserved or with youth with chronic illnesses and/or intellectual disabilities.
Based on your current interests or past research experiences, are there any specific research topics or potential projects that you
would like to propose for a Research Assistant position in our Division? (It’s OK to leave this space blank.)
Please list 3-5 true strengths and 3-5 true weaknesses. Make sure we know which are which!
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Federal, state and local law prohibit discrimination because of age, race, creed, color, religion, sex, national origin,
citizenship status, disability or sexual preference.
I certify that all matters contained in this application are true, authorize their investigation and agree that any
misleading or false statements would render this application void and would be sufficient cause for immediate
dismissal from the Program. I understand that acceptance into the Program is subject to a satisfactory completion
of a medical examination and receipt by CCMCNY of two satisfactory references.
I acknowledge that I will treat as confidential all information that I may read or hear, directly or indirectly. If
accepted for the Program, I agree to conform to the rules and regulations of Northwell Health. I understand that
I will be required to attend an Orientation Program and participate in any training specific to my
assignment. I acknowledge that Northwell Health may discontinue my status at any time and for any reason.
Signature of Applicant:_______________________________________ Date: ______________________
The following materials are required and must be submitted along with your application prior to the
deadline:
Résumé or CV
Unofficial college transcript (an official transcript will be required prior to hire)
A writing sample (for Nephrology only).
Please note:
References are not required at this time; however, the most promising candidates may be asked
to provide contact information for two or more faculty members.
A writing sample is not required from the other 4 divisions; however, this also may be
requested from the most promising applicants.
Students with the strongest application will be invited for an interview (either in person or by
telephone or by Skype).
Contact Info and Application Deadlines:
Developmental & Behavioral Pediatrics: Christine Peck ([email protected]), Due: 3/2/20
General Pediatrics: Caren Steinway ([email protected]), Due 3/4/20
Medical Genetics & Human Genomics: Dr. David Tegay ([email protected]), Due:
3/4/20
Pediatric Nephrology: Dr. Christine Sethna ([email protected]) and Kisha Laurent
([email protected]), Due: 3/4/20
Pediatric Emergency Medicine: Marie Amlicke ([email protected]), Due: 3/4/20
Submitting the Application: All correspondence, including application materials, should be sent by e-mail
to the individual identified above; the subject line should specify "Gap Year Research Internship Application
– Last Name, First Name".
• Early submittal of applications is strongly encouraged. Although students may apply for an internship
position in more than one division, they may not accept more than one internship position.
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