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Application for Post-Doctoral Fellowship - Harbor-UCLA Psychology

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					                         Application for Postdoctoral Fellowship 2012-2013
                                             Harbor-UCLA Medical Center
                                               Department of Psychiatry
                                                  Psychology Division
                                              1000 W. Carson St., Box 488
                                                 Torrance, CA 90509
Instructions: Complete this form by answering all questions. Please do not use font sizes of less than 10 point for any
of your responses. After completion of this application form, please email it along with a copy of your CV to Catherine
Bustamante at CBustamante@LaBioMed.org OR mail hard copies, along with your letters of recommendation to:

                     Catherine Bustamante, Psychology Division/ Department of Psychiatry
                     Harbor-UCLA Medical Center
                     1000 West Carson Street, Box 488
                     Torrance, CA 90509

NOTE: To enter your responses, first click on the shaded areas of the text entry fields. Most text fields allow
for text longer than the shaded space (e.g., “Name” field); however, some fields are limited to the desired
number of character spaces (e.g., text boxes for short answer responses on page 2).

Name:

Sex          --- Click to select option --- If other, please specify

Ethnicity    --- Click to select option --- If other, please specify
(optional)

U.S. Citizen?    --- Click to select option ---     Resident Status:

Mailing Address:



Work Telephone:      (    )       -
Home Telephone:      (    )       -
Cell Telephone:      (    )       -
Email:                        @

Doctoral Education in Psychology:
   Program APA Accredited? (REQUIRED) --- Click to select option ---

      Program Name/Department/Institution:



Pre-doctoral Internship:
    Program APA Accredited? (REQUIRED) --- Click to select option ---

      Program Name/Department/Institution:



List names and telephone numbers for the following three required references. (You may send additional
letters of recommendation (LORs) if you wish.)
APA Graduate Program Director/DCT (required):      (   )     -       (Must confirm anticipated completion date)
Pre-Doctoral Internship Director (required):       (   )     -
Other:                                             (   )     -

I grant permission for Harbor-UCLA Medical Center to contact my references directly:     --- Click to select option ---


                                                           Page 1
                                                Clinical Experience

Briefly characterize your clinical orientation (please keep responses limited to 1000 characters):




List the type of settings in which you have had clinical experience:




Therapy Experience: Summarize your experience, including ages, races, diagnoses, and interventions used:




                                                         Page 2
Experience in Medical and Healthcare Settings (e.g., Specific diseases with which you have worked, work you have
done)




Psychiatric Inpatient Experience (Adult or Child):




Testing Experience: Summarize your experience, including ages, races, and diagnoses (Please note that different
tracks may have different emphases, and may not require all the testing experience listed here):




                                                     Page 3
Assessment Techniques: List test names and approximate number of administrations for each technique listed:

Assessment Techniques: Intelligence:




Assessment Techniques: Neuropsychology:




Assessment Techniques: Objective Personality:




                                                     Page 4
Assessment Techniques: Projective:




                                             Research Experience
Briefly outline the research projects you have completed or on which you are currently working:




                                                       Page 5
                                                     Other Information

Languages other than English you speak:         1)
                                                                          Fluent?      --- Click to select option ---

                                                2)
                                                                          Fluent?      --- Click to select option ---

                                                3)
                                                                          Fluent?      --- Click to select option ---


Are you available for a personal interview at your expense?                            --- Click to select option ---


Are you available for telephone interviews at our expense?                             --- Click to select option ---


Will your dissertation oral examination be completed by August 31, 2012?               --- Click to select option ---


Will all your requirements for the Doctoral degree be completed by August 31, 2012? --- Click to select option ---


Will you have officially graduated by August 31, 2012?                                 --- Click to select option ---



Please indicate the one specialty area of the Harbor-UCLA program to which you wish to apply:

        Choice --- Click to select option ---




How did you hear about our Postdoctoral Program (please check all that apply):

                Former Postdoctoral Fellow
                At Internship
                APPIC Website
                Harbor-UCLA Psychology Division Website
                I was a Practicum Student at Harbor-UCLA Medical Center
                Other (explain):




                                                          Page 6
Personal Statement

Please use this space to tell us what you seek in a post-doctoral fellowship at Harbor-UCLA Medical Center
(space limited to 3000 characters).




                                                      Page 7

				
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posted:11/26/2011
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