Harvard T.H. Chan School of Public Health
Program Application
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Program Name
Program Code
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CFN
GTC
HFM
LDP
LEH
PPCR
PCCS
WOB
MHF
WEX
MHS
MHL
Program Prefix
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Please select the course dates for which you would like to register:
Month DD, YYYY - Month DD, YYYY
EXAMPLE: February 16, 2022
-
February 18, 2022
$X,XXX Standard Price
Registration Started Calculation
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Iteration ID
Program Name
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Who are you registering for this course?
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Questions - LEH, WOB
With reference to your career trajectory, how will attendance in this program contribute to your continued professional development? i.e. What is your primary motivation for further developing skills and knowledge related to health equity
With reference to your career trajectory, how will attendance in this program contribute to your continued professional development? i.e. What is your primary motivation for taking this course?
Please provide information about any previous or current board experience, including the names of the organizations.
List the top two leadership challenges you are facing?
Current Major Professional Memberships: Include Organization, Offices held and dates:
Please describe your participation in any management training programs. Include dates and degree/certificate awarded.
Have you ever applied to and/or attended previous Harvard Executive Education Programs? If yes, please indicate the Program name(s), whether you applied/attended, and dates:
Yes
No
If yes, please indicate the Program name(s), whether you applied/attended, and dates:
Who will the program fee be paid by?
Questions - LDP, PCCS
Please provide your non-academic management title
Please select...
Division Chief
Medical Director
Vice-Chair
Other
If you chose 'Other,' please describe:
Please provide your non-academic management title
Please select...
Chair
Other
If you chose 'Other,' please describe:
Please describe the broad areas of endeavor in which you have engaged, and distinguish between professional (e.g., teaching, research, clinical practice) and management activities:
Please describe your participation in any management development programs. Include Institution, Inclusive Dates, Degree/Certificates, Major/Field.
Have you ever applied to and/or attended previous Harvard Executive Education Programs? If yes, please indicate the Program name(s), whether you applied/attended, and dates:
Yes
No
If yes, please indicate the Program name(s), whether you applied/attended, and dates:
Current Major Professional Memberships: Include Organization, Offices held and dates:
How did you learn of this program?
Describe your hospital organization: its purpose; its services and patients; several measures of its size (e.g.., annual budget, revenues, expenditures; number of employees, patients or beds); medical school affiliation. Email organizational chart, if available.
Describe your role in the organization, including: current responsibilities:
Please make note of any relevant strengths or weaknesses in your background or in your ability to carry out your professional responsibilities:
Name, title/position of individual(s) to whom you report:
Provide number and type of individuals or groups you supervise, as well as the number of beds in your service:
Size and type of budget(s) you control:
Name of principal committees on which you sit:
With reference to your present and future responsibilities and development, what are you primarily interested in learning in this program? Please note subject areas you are well-versed in and those which you feel need improvement.
List the top three management challenges you are facing:
Medical School with which your service is affiliated:
Program fee will be paid by:
Questions: Foundations of Mental Health Care
What is your current set of responsibilities for mental health care and services?
What is your primary motivation for taking this course?
List the top two mental health leadership challenges you are facing.
Please list the programs you would like to register for:
Program 1: Foundations of Mental Health Care
Program 2: Scaling Up Mental Health Care
Program 3: Mental Health Care Peer Learning Collaborative
Questions: Mental Health Leadership
What is your current or anticipated set of responsibilities for mental health care, services or policy?
What is your primary motivation for taking this course? What knowledge and skills do you expect to gain?
List the top two mental health leadership challenges you are facing in your area of responsibility.
Questions: Emerging Women Executives in Health Care
Detail your current title, organization, your responsibilities, and the number of years spent in this job. If applicable, please include the number of staff and/or units reporting to you and the value of the budget to which you are responsible.
Please list the title of the person to whom you report:
Please list any additional leadership experience or positions you have held outside your organization(s) (such as board appointments, professional associations, etc.).
Questions: Conflict, Feedback, and Negotiation for Physician Leaders
Please write 2-3 sentences about what you hope to get from this program:
Questions: Financial Management in Health Care for Non-Financial Managers
Please write 2-3 sentences about what you hope to get from this program:
Other Questions
Emergency Contact Name
Emergency Contact Email
Emergency Contact Phone
How Did You Learn About This Program?
Please select...
Brochure or Flyer
Colleague Recommendation
Email Message
Link on Harvard Website
Link on Other Website
Online Advertisement
Print Advertisement
Professional Association
Search Engine
Social Media
Other
Please specify:
How Did You Learn About This PPCR Program?
If You Chose 'Other' Please Describe:
Please enter any additional notes, e.g., dietary restrictions or any special needs.
Please select how you would like to pay:
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Pay in two installments of 50% each
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