Diabetes Certificate Scholarship Application

In order to be considered for a scholarship, applicants must provide healthcare services to residents living with diabetes or prediabetes in Stockton or San Joaquin County, CA, as this is our target area. The scholarship will cover 100% of the tuition and requires students to complete all courses in the specific track for which they've applied in order to receive the Certificate (all 3 courses for the Non-Clinical track, or all 5 courses for the Clinical track). For the Clinician's program only, students may meet virtually with the instructor to design an individualized plan to complete sections of the course relevant to their practice settings, claim partial CME credit and forgo the Certificate.

General Information

First name *

Last name *

Street address *

City *

State *

Zip code *

Email address *

Phone number (numbers only) *

Date of birth * +

To which program are you applying? *

Clinicians (e.g. licensed healthcare professionals)

Non-Clinicians (e.g. CHWs, non-licensed healthcare workers )

Please check one or more of the following groups in which you consider yourself to be a member: *

Hispanic or Latino

American Indian or Alaska Native

A race/ethnicity not listed here

Asian (Including Indian subcontinent and Philippines)

Black or African American (including Africa and Caribbean)

Native Hawaiian or other Pacific Islander

White

I'd rather not say / decline to answer

Learner and Impact Information

Please answer a few questions that will help us determine the reach of this program and the diversity of the people you impact.

These next questions refer to people with or at risk for prediabetes/diabetes that you impact.

1. Do your patients with prediabetes or diabetes live in Stockton, CA? *

Yes

No

1a. Please estimate the number of people you impact each calendar year who reside within these Stockton, CA zip code areas: 95201, 95202, 95207, 95203, 95206. *

1b. In which State(s) do they live? *

In which County / Counties? (Must include San Joaquin County, CA to be considered for this scholarship) *

1c. Please estimate the TOTAL number of people with prediabetes or diabetes you impact in a calendar year: *

2. Which of the following best describes their predominant race(s) or ethnicity(s)? (Check all that apply) *

3. What is their primary language(s) used while seeking your support? (Check all that apply) *

4. What is their gender / sexual orientation? (Check all that apply) *

5. Select your professional credential, certification or role (check all that apply): *

6. Where do you provide diabetes prevention or care? (select all that apply) *

7. What is your specialty? (select all that apply) *

8. What is your age? *

9. Please share what motivated you to take this course/program. *

Receiving a scholarship will be a deciding factor to attend

I want to improve my knowledge and skills

I need continuing education units

I hope it will prepare me for a new role

A colleague spoke highly about it

N/A or prefer not to say

Other (fill in below) Other (fill in below)

10. How did you learn about this program? *

11. I understand the following once my application has been reviewed and accepted:
• I'm required to cover a one-time, non-refundable application processing fee ($50 for Clinicians or $25 for Non-Clinicians). After payment received, I will be enrolled in the course within 10 business days.
• The scholarship covers 100% of the tuition for the Diabetes Essentials Certificate Programs: Clinicians ($995) and Non-Clinicians ($295).
• This comprehensive program is self-paced and requires my consistent effort to complete the coursework within a year for Clinicians (up to 100 hours), and within 4 months for Non-Clinicians (30 hours).
• I will start course within 2 weeks of being enrolled, and budget about 2 hours per week on average in order to finish in time frames listed above. I can dedicate more time and finish sooner.
• Funding for this program is contingent on the acceptance of my application and ability to complete the program, so if I'm not actively doing coursework for a month, and am not responsive to a series of instructor's emails, I will be dropped from the course. Exception - if prior arrangements made with instructor for extended vacations, leave of absence, illness, maternity leave, just needing a break, etc.
• The role of the instructor is to support my efforts and answer questions but not to remind me to do the coursework. I will communicate with the instructor when I anticipate pauses in my ability to do the coursework.

We want you to succeed in completing this dynamic program aimed at helping you in improving the care and outcomes of those living with prediabetes and diabetes! *

Yes, I understand and agree to the above. Yes, I understand and agree to the above.

Employment

Please provide your current employment information below.

Agency/Company *

Location *

Title *

Start date * +

Briefly describe responsibilities *

Abbott Fund Scholarship

Students who help people with prediabetes or diabetes in Stockton or San Joaquin County, CA, may apply for the Abbott Fund Scholarship that covers 100% of the tuition for the Diabetes Essentials Certificate program at University of the Pacific and be a part of the Future Well Communities initiative.

Please attach a Word document answering the following questions if you would like to be considered for the scholarship. There is no maximum word count requirement.

Why is learning about diabetes education and care important to you?
How will this certificate program serve you in your current position specifically?
*Optional: Briefly describe your financial need for this scholarship

PLEASE NOTE:

~If you're selected to receive this scholarship (and after completing course requirements), you'll be asked to provide feedback on the impact this program has had on you and/or the community you serve. This is for internal purposes only and will not be published on our website in any format without your explicit written permission to do so. The intent is to share the collective good this will have. Format: either a 1-minute video or a clear photo of you with a paragraph describing how being an Abbott Fund scholarship recipient helped your role and/or the community you serve. Photo or video not mandatory but encouraged.

~Up to 100 hours CME credit is available for the Diabetes Essentials for Clinician's course (AACME and ACPE).

~Expect feedback on your application typically within 3 business days and know that access to the course may take an additional 10 business days due to the volume of applicants.

Thank you!

Attach document *