Welcome to the Duke Advanced Practice Provider Institute (APPLI) online program application. We look forward to learning about you and your professional experiences.
The Team Lead must complete this application entirely. Incomplete applications will not be considered.
Team Leads are responsible for answering all questions in the online questionnaire and ensuring that all application materials are submitted in a timely manner.
A complete application packet includes this online application, the online Team Partner application(s), and the completed Employer Letter of Commitment (LOC) for each team member . If you have not already downloaded the Employer LOC from the program website, click here to download it, acquire the needed signatures and upload the completed document with your online application.
A link to the required Team Partner application will be emailed to each Team Partner. So, please be sure to enter the appropriate email address(es). Team Partner applications must also be complete for the team application to be considered.
You may save an incomplete application and return to it later.
If you have questions about completing this application, please contact APPLI@duke.edu .
To begin the application, please fill in the fields below.
First Name
* must provide value
Last Name
* must provide value
Email Address
* must provide value
Current Employer/Organization
Team Lead Profile Checklist
I am a/an
* must provide value
Certified Nurse Midwife
Clinical Nurse Specialist
Nurse Practitioner
Physician Assistant
Physical Therapist
Other type of graduate-degree trained provider, e.g., LCSW, MFT, OT, PharmD, etc. (Please specify below)
None of the above
If Other type , please specify.
I am employed in the United States.
* must provide value
Yes No
I have two or more years of experience supporting, developing, or managing an APP-managed practice, service or unit (including your current clinical practice setting) OR I am in a position to advance into this role in the near future.
* must provide value
Yes No
I have experience providing services for a vulnerable patient population.
Vulnerable populations, with respect to health, are groups and communities that often have been historically excluded and subjected to systems and processes that have put them at a disadvantage for optimal health and well-being. The barriers experienced by these individuals can be related to race, ethnicity, culture, religion, age, gender, or sexual orientation, as well as factors such as occupation, income, health insurance coverage, absence of a usual source of care as well as limitations due to illness or disability. Their health and healthcare issues may also intersect with social factors, such as education, occupation, geography, housing, and poverty.
* must provide value
Yes No
I have experience providing integrated/comprehensive care services."Integrated/comprehensive care" is a concept that involves bringing together the organization, delivery and management of services related to diagnosis, treatment, care, rehabilitation and health promotion in a way that provides continuity for and partnership with patients, families and communities.
* must provide value
Yes No
Upload a copy of your current CV here.
Please tell us how you learned of this program.
* must provide value
Program Newsletter
Program Website
Program's Social Media (Twitter, Facebook)
Professional Association (ex. NCAPA, AANP, etc.)
Conference/Workshop Exhibit
Colleague/Employer
APPLI (or Duke-Johnson & Johnson) Program Fellow or Alumni
Other APPLI (or Duke-Johnson & Johnson) Program Affiliates (e.g., staff, advisory board members, project coaches, program presenters)
Program Email Announcement
Other
Check all that apply
Please specify the other or specific professional association.
Team Lead Contact and Demographic Information
State
* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia(DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Country
* must provide value
Female
Male
Other
Prefer not to respond
If other, please specify.
Race/Ethnicity or National Origin
White
Black/African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Hispanic/Latino
Other race
Two or more races
If Other race , please specify.
Team Lead Current Organization/Employer Information
Organization/Company Name
State
* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia(DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Identity of person who will submit the employer's Letter of Commitment on your behalf
FQHC/Look Alike
Rural Health Clinic
Migrant Health Center
Health Department
Homeless Healthcare Program
Non-Federal Free Clinic
AIDS Service Organization
Academic Health Center Program
University/College System
Corporate Health and Wellness
School Clinic
Behavioral Health Service
Private Practice
Community Practice (Health Center)
Indian Health Service
APP owned clinic
Hospital owned clinic
Physician owned clinic
Corporation/Network owned clinic
Other
Select all that apply
If other, please specify.
Describe your clinical practice setting (100 words or less).
Indicate the average
Indicate the number of patients served by your clinical practice per year.
Indicate the number of employees who directly report to you.
Organization/Company Name
Employment Start Date (MM/YYYY)
Employment End Date (MM/YYYY)
Job Responsibilities (maximum 3 sentences)
Would you like to add a 2nd past employer?
Yes No
Organization/Company Name
Employment Start Date (MM/YYYY)
Employment End Date (MM/YYYY)
Job Responsibilities (maximum 3 sentences)
Would you like to add a 3rd past employer?
Yes No
Organization/Company Name
Employment Start Date (MM/YYYY)
Employment End Date (MM/YYYY)
Job Responsibilities (maximum 3 sentences)
Enrollment Start Date (MM/YYYY)
Enrollment End Date (MM/YYYY)
BSN
DPT
MOT
MSN
ODT
PA
MPH
MSW
MHS
MBA
DNP
PharmD
PhD
MD
Other
If other, please specify.
Would you like to add another degree?
Yes No
Enrollment Start Date (MM/YYYY)
Enrollment End Date (MM/YYYY)
BSN
DPT
MOT
MSN
ODT
PA
MPH
MSW
MHS
MBA
DNP
PharmD
PhD
MD
Other
If other, please specify.
Would you like to add another degree?
Yes No
Enrollment Start Date (MM/YYYY)
Enrollment End Date (MM/YYYY)
BSN
DPT
MOT
MSN
ODT
PA
MPH
MSW
MHS
MBA
DNP
PharmD
PhD
MD
Other
If other, please specify.
Would you like to add another degree?
Yes No
Enrollment Start Date (MM/YYYY)
Enrollment End Date (MM/YYYY)
BSN
DPT
MOT
MSN
ODT
PA
MPH
MSW
MHS
MBA
DNP
PharmD
PhD
MD
Other
If other, please specify.
Prepared and Credentialed as:
Registered Nurse
Nurse Practitioner
Clinical Nurse Specialist
Certified Nurse Midwife
Physician Assistant
Clinical Social Worker
Pharmacist
Occupational Therapist
Physical Therapist
Other
If other, please explain.
Today M-D-Y
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia(DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Would you like to add another item to this section?
Yes No
Prepared and Credentialed as:
Registered Nurse
Nurse Practitioner
Clinical Nurse Specialist
Certified Nurse Midwife
Physician Assistant
Clinical Social Worker
Pharmacist
Occupational Therapist
Physical Therapist
Other
If other, please specify.
Today M-D-Y
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia(DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Would you like to add another item to this section?
Yes No
Prepared and Credentialed as:
Registered Nurse
Nurse Practitioner
Clinical Nurse Specialist
Certified Nurse Midwife
Physician Assistant
Clinical Social Worker
Pharmacist
Occupational Therapist
Physical Therapist
Other
If other, please specify.
Today M-D-Y
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia(DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Would you like to add another item to this section?
Yes No
Prepared and Credentialed as:
Registered Nurse
Nurse Practitioner
Clinical Nurse Specialist
Certified Nurse Midwife
Physician Assistant
Clinical Social Worker
Pharmacist
Occupational Therapist
Physical Therapist
Other
If other, please specify.
Today M-D-Y
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia(DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Volunteer Organization Name
Leadership Positions and Activities
Would you like to add another item to this section?
Yes No
Volunteer Organization Name
Leadership Position and Activities
Would you like to add another item to this section?
Yes No
Volunteer Organization Name
Leadership Position and Activities
Would you like to add another item to this section?
Yes No
Volunteer Organization Name
Leadership Positions and Activities
List any management or leadership training you have had within the last three years related to your work as a health care leader. If you have received no training during this period, state "None". (300 words maximum)
As a valuable contributor in your organization, what would you like to help your organization do better? What are possible strategies to help address the matter? (300 words maximum)
* must provide value
What is a creative or innovative work project you have helped to develop, and what impact has it made? (300 words maximum)
* must provide value
If your team is selected to participate in the APPLI program, you will be expected to develop and launch a health improvement project during the program year that implements clinical, education, and/or advocacy innovation (See here for more details). Please solicit input from all applicant members regarding the questions below and be sure that your responses are reflective of your team members' feedback.
What preliminary ideas do you have for a project (i.e., goal, target population, outcomes of interest)? (200 words maximum)
* must provide value
Identify the proposed specific role that each team member would share in relation to the project. (200 words maximum)
* must provide value
What organizational challenges (e.g., structural, cultural, financial) do you foresee needing to address in order to ensure your project's success? (200 words maximum)
* must provide value
Would you like to share any additional information? (200 words maximum)
Why do you want to participate in this program? (200 words maximum)
* must provide value
What do you think are the strengths of your team? (200 words maximum)
* must provide value
What do you think could be an area of growth/improvement for your team? (200 words maximum)
* must provide value
Will you be concurrently enrolled in another training program while participating in Duke APPLI?
Yes No
What is the program and when is the planned completion date? (200 words maximum)
What is the plan to address the challenges of being concurrently enrolled in both programs, including scheduling conflicts and the added time demands? (200 words maximum)
How many team partners will be on your team (a max of three is allowed).
* must provide value
One
Two
Three
First Name
* must provide value
Last Name
* must provide value
Email Address
IMPORTANT: The Team Partner application will be mailed to this email address. Please ensure that your team partner checks this email account routinely and completes the Team Partner application in a timely manner. Your application packet will not be reviewed until all team partner applications have been submitted.
* must provide value
Allied Health Professionals
Audiologists
Fellows
Medical Students
Nurse Practitioners
Nurses
Pharmacists
Pharmacy Technicians
Physician Assistants
Physicians
Residents
Speech Pathologists
Other
Select all that apply
If other, please specify.
Female
Male
Other
Prefer not to respond
If other, please specify.
Race/Ethnicity or National Origin
White
Black/African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Hispanic/Latino
Other race
Two or more races
If Other race , please specify
First Name
* must provide value
Last Name
* must provide value
Email Address
* must provide value
Allied Health Professionals
Audiologists
Fellows
Medical Students
Nurse Practitioners
Nurses
Pharmacists
Pharmacy Technicians
Physician Assistants
Physicians
Residents
Speech Pathologists
Other
Select all that apply
If other, please specify.
Female
Male
Other
Prefer not to respond
If other, please specify.
Race/Ethnicity or National Origin
White
Black/African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Hispanic/Latino
Other race
Two or more races
If Other race , please specify
First Name
* must provide value
Last Name
* must provide value
Email Address
* must provide value
Allied Health Professionals
Audiologists
Fellows
Medical Students
Nurse Practitioners
Nurses
Pharmacists
Pharmacy Technicians
Physician Assistants
Physicians
Residents
Speech Pathologists
Other
Select all that apply
If other, please specify.
Female
Male
Other
Prefer not to respond
If other, please specify.
Race/Ethnicity or National Origin
White
Black/African American
American Indian or Alaska Native
Asian
Hawaiian or Pacific Islander
Hispanic/Latino
Other race
Two or more races
If Other race , please specify
Employer/Supervisor of Team Lead
First Name
* must provide value
Last Name
* must provide value
Organization/Company Name (if different than your current employer):
Employer/Supervisor of Team Partner
Employer/Supervisor of Team Partner #1
First Name
* must provide value
Last Name
* must provide value
Organization/Company Name
Employer/Supervisor of Team Partner #2
First Name
* must provide value
Last Name
* must provide value
Organization/Company Name
Employer's Letters of Commitment
Instruction: Please save all of the team's letters together as one PDF. The team lead letter should be the first in the document, followed by the letter for Team Partner #1 and then Team Partner #2 (if applicable). Name the PDF "TeamLeadLastName_ELOC" and upload the file here.
If accepted as a Duke APPLI Program Fellow:
I will participate fully in the program by attending all required sessions as noted in this calendar of events and making contributions to group learning through exchanges of ideas with others during both live and asynchronous activities. I will share with others the knowledge that I gain as a program participant for the purpose of improving health outcomes for all. I will fully be engaged with all my team members in developing a team project, the implementation of which is intended to have a positive effect on health care delivery to underserved populations and others. I will participate in ongoing evaluations of the program. I will participate in ongoing evaluations of my professional development and my organization's progress resulting from my participation in the program. I additionally acknowledge the program fees of $4,175 as listed on the Duke APPLI website , and agree to remit payment within 14 days of acceptance into the program, or a later date agreed upon by Duke APPLI program staff. By submitting this application, I agree to the commitments as stated above if I am accepted to the program. I also hereby certify that the information and any attached documents provided by me in this application are complete and correct to the best of my knowledge. Please sign your name in the box below to serve as your electronic signature.
* must provide value
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