HPSP

Message from the Branch Chief

To all the AFHPSP and Educational Delay applicants:

As you embark upon your application for future training, I want congratulate you for successfully completing most of your
medical education. You are among the best and brightest physicians in our nation and we are proud that you have chosen to serve
in the Air Force Medical Corps. We stand ready to assist you in any way we can to help you make the best decisions about your
future career.

Every year, the Air Force projects how many physicians in each specialty are required to meet the needs of the Air Force
Medical Service (AFMS). This process, called “forecasting”, is completed in May/June of each year by the Health Professions
Education Requirements Board (HPERB). The number of physician requirements forecasted for each specialty is posted on our
web page, along with the number of training positions that will be available at this year’s Joint Service GME Selection Board
(JSGMESB). As is the case nationwide, some specialties are more competitive than others. Currently our most popular
specialties are Anesthesiology, Radiology, and Emergency Medicine and these specialties will be more competitive compared to
the primary care specialties such as Internal Medicine, Family Medicine, and Pediatrics. If non-selected for your specialty choice,
you will be offered a PGY 1 only training contract in Transitional Medicine, Internal Medicine or General Surgery. Completing
your PGY 1 year ensures that you are eligible to take and pass USMLE/COMLEX Step 3, and obtain a valid, unrestricted, state
medical license according to the terms of your contract.

 Please note that most active duty reporting dates for your PG1 only year or residency training will normally be in the
first week in June or soon thereafter.

 If you decide to change your 2 page DOD training location preferences, PG1 only training locations, or your Second
Choice form training locations for any reason please do not send these changes via email, voicemail, or on faxed bond
paper. AFPC/DPAME will only accept faxed training changes completed on the second page of the 2 page DOD
application, PG1 only page, or Second Choice JSGME Core documents with a valid date and signature. Please fax all
training locations changes to AFPC/DPAME no later than 30 October 2009.

 If you don’t know what your security clearance is and the date it was initiated then you need to leave the security
clearance portion of your Education Summary page blank and AFPC/DPAME will complete this portion of the
Education Summary for you.

 If you have questions during the JSGME application process please contact the Medical Student Program Manager by
phone at 1800-531-5800, extension 1, instead of sending your questions via emails. Email traffic is extremely high
during this time and by utilizing the phone to ask your questions we will be able to answer questions more timely.
Phone call voicemails will be answered in order of precedence and/or priority.

 You must apply to, and be selected by, the 2009 JSGMESB to enter a Graduate Medical Education program in 2010. If
you are not selected for the specialty of your choice, you will be approved to enter a PGY-1 only internship, in
Transitional Medicine, Internal Medicine or General Surgery. You may re-apply to the 2010 JSGMESB for specialty
training beginning in 2011, or you may serve an operational tour in Flight Medicine after completing a PGY 1 year.
The training opportunities available at the JSGMESB are specific. For instance, if you have been selected for a 5 year
General Surgery residency you may not enter a program that requires a sixth research year unless approved to do so by
my office. Similarly, if you are offered a PGY 1 only internship year in Transitional Medicine, Internal Medicine or
General Surgery, you may not start a program in Pediatrics or Emergency Medicine simply because a civilian program
is willing to offer you a position.

 All HPSP medical students must apply through their respective matching programs. You should enter the National
Residency Match Program (or Osteopathic equivalent) Electronic Residency Application Service (ERAS) for a PG1
year only in Internal Medicine, General Surgery or a Transitional year beginning 1 July 2009. You must withdraw
from the match if selected for training in an active duty program by the JSGMESB. You will apply through ERAS at
the same time you are submitting your JSGMESB application to this office. This will ensure if you are non-selected
for a categorical residency through the JSGMESB and selected for a deferred PG1 year only that you will have your
civilian application updated for a deferred PG1 year only with ERAS in a timely manner. You will also complete an
ERAS application through the NRMP if you selected a deferred training position for categorical residency on your two
page DOD JSGME application. If selected for an Air Force residency program, applicants must withdraw from the
civilian match and notify the medical school office. The school should be informed immediately upon release of the Air
Force GME Selection Board results by HQ AFPC/DPAME.

 You will receive an email checklist each time there is an administrative update or change with your application, such as
new documents received. Review carefully for accuracy. Do not reply to the email checklists, as they will be
automatically deleted.

 All medical students must obtain their Medical or Osteopathic Degree prior to being authorized to travel to residency
training.

 GME selection for categorical residency training is contingent upon successful completion of USMLE or the
COMLEX Step I and STEP II tests. The USMLE and COMLEX STEP 1 and STEP 2 tests will be due no later than
 HPSP
23 October 2009 to DPAME. Test results are released from the NBME/NBOME within 4 to 6 weeks after your test
date at the earliest, so schedule your test dates accordingly to meet the JSGMESB timeline deadlines.

 All AFHPSP applicants must complete an Active Duty Tour (ADT) at one of the Air Force’s teaching facilities. The
active duty tour in a clinical internship/specialty enables you to meet the JSGMESB interview requirement. To meet
this requirement, ensure you schedule an interview specifically with the Program Director. This is particularly
important for your number one training location and specialty choice. Upon arrival at your active duty tour location
please be sure to schedule an appointment with your program director for a face to face interview. If you apply for a
different training location or specialty choice other than where you completed your active duty tour, you will need to
complete an interview (preferably in person; however, telephonic is acceptable) with one active duty (Air Force)
Program Director in that specialty. Applicants applying to Neurosurgery must interview with the Air Force
Neurosurgery Consultant as there is no Air Force Active Duty Program.

NOTE: In the event the Program Director is deployed, an interim Program Director will be appointed. Ensure you
contact either the program director or his/her designee if program director is deployed.

All applicants meeting the selection board are required to obtain a DOD Interview form. Your program manager will
provide updates to the application as various supporting documents arrive within DPAME. If you still have the DoD
interview sheet as an outstanding document by the end of Oct, please do not contact Mr. Kush, contact the program
director for your 1st location preference

 All medical students completing an ADT can receive a possible maximum of 3 additional points toward their overall
JSGMESB score. Please make sure you schedule your ADT’s with AFIT by contacting Kelly Adams at 1800-543-
3490, extension 3034. We suggest you complete this at your earliest convenience before the ADT training vacancies
are filled. Educational Delay students will not be penalized for not completing an ADT by the JSGME board.

 Air Force Program Director/Consultants may only review a copy of your DOD application and CV. They may not
request additional materials such as photographs, board scores, essays, or letters of recommendation.

 JSGMESB deadlines are firm. Late applications will be returned without action and will not meet the board. Fax or
emailed copies of the JSGMESB application will not be accepted by DPAME.

 The application essay is your opportunity to tell the selection panel why you are applying for that specialty. We know
you chose a career in medicine so don’t waste space repeating why you wanted to become a physician. Focus on the
specialty you have chosen. All essays must be double spaced, no less than 10 Font, Times New Roman, and with 1 inch
margins. Use the last paragraph to identify extenuating circumstances. Examples: Married to another military
medical student, illness of a family member and requesting deferment. Provide supporting documentation with
your essay to support your request (marriage certificate or a letter from a doctor documenting an illness in your
family). Simply stating that you have a fiancée for instance, will not qualify you for any special consideration. Follow
the format guidelines (length, font…) or we will ask you to retype your essay.

 Letters of recommendation may not be completed by active duty Program Directors, because they will be scoring your
JSGME application at the JSGME board and this is considered a conflict of interest item. Their comments are
incorporated and captured through the DOD Interview Form. Only submit 2 letters of recommendation to DPAME.
Switching out letters will not be permitted. In the event a third letter is received it will be destroyed.

 Only submit official USMLE/COMLEX Test Scores. Letters from agencies such as student affairs will not be
accepted.

These remarks are meant to highlight some key points. There is additional detailed information in the instructions
accompanying your application. Please work closely with the Medical Student Program Manager, Mr. Matthew Kush, (210) 565-
0656, 1-800-531-5800 Ext 1. My Section Chief, Ms Dayan Geiger, or I, will be happy to speak with you as well, (210) 565-
2638/9, 1-800-531-5800.

I wish you the best of luck with your application and future training endeavors!

Original Signed
THOMAS GRAU, Col, USAF, MC
Chief, Physician Education Branch
 HPSP
United States Air Force
2009 Joint Service Graduate Medical Education Selection Board (JSGMESB) Application

HQ AFPC/DPAME Medical Student Program Manager: Toll free (800) 531-

550 C STREET WEST STE 27 5800 ext 1
RANDOLPH AFB, TX 78150 Comm (210) 565-0656, DSN 665-0656

JSGMESB Application Timeline

 HPSP
Core Application Deadline
Core Application Deadline 4 September 2009, or sooner
1. DoD 2-page Application for GME
Submit this form asap. Do not wait until deadline – it can be mailed alone, while
you continue to gather and submit the remainder of core application items by
4 September 2009 (see below).

2. (DoD Application, Curriculum Vitae (CV), Second Choice, PG1 Only,

Statement of Understanding, Race/Ethnic voluntary disclosure, Education 4 September 2009
Summary, and personal essay.
1. Early submission to AFPC/DPAME is encouraged.
2. Ensure you only mail a copy of the 2-page DoD application and CV to the
active duty program director(s) in the specialty (ies) you are applying for.
3. Incomplete Core application documents received by AFPC/DPAME will
not be accepted and the applicant will be required to re-accomplish the
document. (See the JSGME instruction package on how to fill out these
documents). Be sure to sign/date the documents where required.
Weight Statement Weigh in 5 – 9 October 2009
(Note mandatory weigh in dates) Must weigh in between 5 - 9 October 2009 Submit by 13 October 2009

Two original letters of recommendation with signatures and dates 5 October 2009
Dean’s Letter released 2 November 2009

Dean’s letter and transcripts due to DPAME

It is the medical student’s responsibility to ensure the Deans Letter is received by 9 November 2009
AFPC/DPAME by 9 November 2009 .
Last Day for Location Preference Changes 30 October 2009
1. All changes must be completed on the second page of the 2 page DOD
application, 2nd Choice Form or PG1 only page and faxed to 210-565-2830.
Please call to confirm receipt.
2. No Changes will be made by telephone, e-mail or faxed bond paper.
Interviews completed 27 October 2009
DOD Interview Sheets to DPAME (submitted by interviewer) 5 November 2009
Step 1 and Step 2 board scores to DPAME 23 October 2009
Joint Service GME Selection Board Convenes 1 – 4 December 2009
JSGME selection results available on line 16 December 2009
Results Will NOT Be Released Before This Date
Written Notice mailed to All Applicants 18 December 2009
 HPSP
JSGMESB Checklist for Success
This checklist outlines all documents required to complete the JSGMESB application. Please review the
JSGEMSB Overview and Application Guidance sections for detailed instructions on each requirement.

Core application documents (due 4 September 2009)

_____ 2-page DoD application (mail this first to DPAME, as soon as possible)
_____ PG1 Only
_____ Curriculum Vitae
_____ Personal Essay (Double spaced, 10 to 12 Font, Time New Roman, and 1 inch margins)
_____ Educational Summary
_____ Second Choice form
_____ Statement of Understanding
_____ Race/Ethnic Voluntary Disclosure

Supporting documents
_____ Step 1 scores (due 23 October 2009)
_____ Step 2 scores (due 23 October 2009)
_____ Dean’s letter (due 9 November 2009)
_____ Official copy of medical school transcript (due 9 November 2009)
_____ Two personal letters of recommendation (due 5 October 2009)
_____ Weight statement (due 13 October 2009)
_____ Program Director interview (Active Duty Tour), complete by 5 November 2009 (interviewers forward
directly to DPAME)
_____ Last Day to make location training preference changes to DOD application by fax to COMM: 210-565-
2830. (30 October 2009).
 HPSP

Section I: Application Instructions

Please read all instructions prior to completing any part of the application package. Compliance with
these instructions will expedite the processing of the application and afford the opportunity for GME
selection.

What is the Joint Service Graduate Medical Education Selection Board (JSGMESB)?
The JSGMESB is a Joint Board comprised of program directors and specialty consultants from the Air Force,
Army, and Navy that convenes annually to select physicians for graduate medical education training programs.
The Air Force selects individuals for training based on training requirements established by the annual Health
Professions Education Requirements Board (HPERB).

Training Opportunities
Health Professions Education Requirements Board (HPERB) convened May 2009 and identified GME training
opportunities based on Air Force requirements. You can only apply for training in specialties that have
training requirements identified. If a desired specialty is not listed in the HPERB results, do not submit a
GME application for that specialty. Training in excess of HPERB requirements is not likely. For example, if
the Air Force has three funded slots at an Air Force location, those three positions will typically be the only
ones filled. Even if the Army or Navy has vacant slots in that specialty, applicants will not be considered for
these training locations if the Air Force has filled their HPERB requirements and funding allocations. Please
note that Air Force programs must be filled prior to granting deferments or training in an Army/Navy program.
Please call Physician Education if you are interested in exploring options for training at an Army or Navy
location.

An applicant may not enter a GME program unless he/she has applied to and has been approved for training by
the GME Selection Board. The results of the HPERB indicate a specific start year for training. Some training
is approved two years in advance, called “pre-select” positions. Pre-select specialties, such as Radiology or
Anesthesiology, have an attached clinical internship year. Please pay particular attention to the specific start
dates and length of training identified by the HPERB.

Download and complete the application on your personal computer. Print the completed application and return
the original, signed copy to DPAME. Do not change the format of any forms or try to submit this application
electronically or via email. Compliance with these instructions will expedite the processing of your
application and afford the applicant the opportunity for selection for GME. All GME documents must be
typed. Handwritten documents will be returned without action.

General Instructions
1. AFHPSP students and ROTC ED-Delay status individuals are required by contract to submit a GME
application to the JSGMESB. If you are an HPSP or AFROTC Educational Delay students and you fail to
submit an application it may result in your benefits being suspended. Failure to submit an application may
result in the consideration for a PG1 only year.

2. The GME application will be in two parts. Part I, the Core Application and Part II, supporting documents.
Please refer to the timelines of when each document is due to ensure timely processing of the application.

The 2009 HPERB has approved a new opportunity for physicians to apply for a combined Family
Medicine / RAM program, beginning in 2010. If selected, the applicant will complete a 3 year Family
Medicine residency at one of the 3 authorized locations from 2010-2013 (Nellis NV, David Grant CA, or
Eglin FL). After, they will complete a one year post training Flight Surgery staff assignment (2013-2014)
at the same location. Then, they will begin Phase 1 of the 2 year RAM program. Phase 1 is the academic
MPH or MS year at any accredited MPH / MS program in the U.S (from 2014-2015). High/Low Cost
program will be determined by the JSGMESB, according to Order of Merit. Phase 2 is the didactic
program at the new School of Aerospace Medicine at Wright Patterson AFB, OH. Training will end in
June of 2016. Applicants should understand that a PG1 repeat will be required for any physician who
has completed a previous internship. Total ADSC incurred will be 4 yrs for 5 yrs of training, however,
the member will fulfill 1 yr of ADSC during the operational Flight Surgery tour from 2013-2014. Please
contact DPAME for additional guidance or questions.

Types of Training
 HPSP
Types of training include sponsored and non-sponsored training. Non-sponsored (unfunded) training is called
Deferred training. Sponsored (funded) training includes active duty training facilities and civilian sponsorship.
An explanation of each type of training is listed below.

Active Duty (Sponsored) Training

Applicants selected for active duty programs incur an obligation for the length of training, year-for-year
commitments after their internship year to be served concurrently with the remaining AFHPSP, prior Active
Duty, AFROTC, or US Air Force Academy commitment. In some instances where the commitment for the
program is longer than the sponsorship commitment, applicants will incur the extra obligation; for example,
applicants that have a 3-year HPSP commitment and are selected for a 5-year General Surgery program will
have that 3-year commitment but will incur an additional year for training. Per US Code, Title 10, the PG1
year in an active duty program does not incur any commitment.

Deferred (Non-Sponsored) Training

Often, Air Force training requirements exceed the availability of sponsorship. For certain specialties, an
option may be available to request training in deferred status at a civilian training facility. There is no
additional obligation for training in deferred status. Applicants selected for deferred training are assigned to
the Inactive Obligated Reserves, considered in a leave of absence status during training, with a remaining
obligation to the Air Force for costs expended during your medical school, prior Active Duty (and/or college
for ROTC or USAF Academy) education. If you are selected for a civilian deferment, you receive a salary
from the training institution. If selected for deferred training, there will be instructions regarding required
documents in the official JSGMESB selection letter. Documents required would be a program directors
selection letter indicating approved training dates that should match your JSGME selected training dates,
training program selected for and the training location. Civilian sponsored physicians are prohibited from
receiving a salary, stipend, or other monetary benefits from the institution for his/her services as a resident or
fellow. DOD and Air Force Instructions prohibit off duty employment while in GME training, regardless of
the civilian institution’s policy.

Physicians applying to civilian training programs do not need an acceptance letter prior to the GME Selection
Board. Individuals may negotiate with Program Directors prior to the Selection Board, but must make it clear
to each Program Director that acceptance of any training offer is contingent upon official written notification
by the Air Force following the GME selection board. Applicants negotiating with their current Program
Director or other programs that have a tentative offer in writing may submit a “Good Faith” letter for inclusion
with their application. This letter does not guarantee selection but shows the board that should you be selected,
you have secured a program. Civilian programs are limited to the continental United States.

Civilian Sponsored Training

Applicants selected for civilian sponsored training will enter active duty, be assigned under the command of
the Air Force Institute of Technology (AFIT), and will receive an Air Force salary and active duty benefits.
Civilian Sponsored Residents will incur a consecutive ADSC for participation in a civilian sponsored
program. This ADSC will be equal to the length of the training and added to any existing ADSC the student
may have. Applicants who have been offered and have accepted civilian sponsorship are encouraged to seek
positions in programs which have affiliations with Veterans Administrations facilities.

Civilian sponsored physicians are prohibited from receiving a salary, stipend, or other monetary benefits from
the institution for his/her services as a resident. DOD and Air Force Instructions prohibit off duty employment
while in GME training, regardless of the civilian institution’s policy.

If selected for Civilian Sponsorship, the applicant has until 15 April 2010 to secure a program and submit the
required documents to DPAME. There will be additional instructions in the JSGMESB offer letter.

Training in an Army, Navy, or Federal Training Facility

Training in an Army, Navy, or other Federal institution requires funding from the Air Force. If the 2009
HPERB authorizes an Army or Navy facility as a training location, an applicant is able to request consideration
for placement at that facility on page two of the JSGMESB application. If a specialty is soliciting “civilian
sponsorship” as a training location, the applicant may request consideration for an Army, Navy or a Federal
institution under the Air Force funding provided there is program capacity. If the HPERB did not authorize
placement in another facility or if civilian sponsorship is not available to convert to an Army/Navy facility,
 HPSP
then the applicant will not be considered for placement outside of the HPERB authorizations as funding will
not be available.

Listing Training Preferences Locations

Even if an applicant is requesting civilian deferment or civilian sponsorship as their first location preference,
medical students must rank at least one active duty Air Force training location and interview with their first
choice active duty program director. To maximize placement opportunities, additional instructions are
included in Section II. Applicants are encouraged to rank all Air Force programs

Training in an Accredited Program

Applicants must request training in specialties reviewed and approved by the Accreditation Council for
Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). Applicants may
apply for dual programs approved at the Health Professions Education Requirements Board (HPERB) only. (a
copy of the HPERB results is posted on this web page). Applicants are encouraged to review the current
edition of the Directory of Graduate Medical Education Programs for allopathic programs and information
published by the AOA for osteopathic training programs.

Entering the Civilian Match

NOTE: IF AN APPLICATION IS SUBMITTED THROUGH THE ELECTRONIC RESIDENCY
APPLICATION SERVICE (ERAS), APPLICANTS MUST ALSO COMPLETE THIS APPLICATION FOR
GME.

All applicants should enter the National Residency Match Program or its osteopathic equivalent. If selected
for an Air Force residency program, applicants must withdraw from the match and notify the medical school
office. The school should be informed immediately upon release of the Air Force GME Selection Board results
by HQ AFPC/DPAME. The board release date is 16 December 2009.

Active Duty Service Commitments (ADSC’s)

ADSC’s are governed by US Code, Title 10 and AFI 36-2107 and vary depending on the length of
sponsorship. ADSC’s cannot be fulfilled while in training and are calculated based on completion dates.

Individuals selected for active duty programs incur year for year commitment for those programs after the
internship year, to be served concurrently with the AFHPSP, prior Active Duty, AFROTC or USAFA
commitment. In rare instances where the commitment for the program is longer than the scholarship
commitment, applicants will incur the extra commitment. EXAMPLE: Students who have a 3-year AFHPSP
scholarship and are selected for a 5-year surgery program. After completion of the surgery program, the
student will have a 4-year commitment for the program and will incur the additional one-year payback.
 HPSP

ADSC for General Surgery Training

Due to the different lengths of training for General Surgery programs, the Chart below outlines the ADSC’s
associated with training lengths for general surgery residency training.
Training Length Completion Dates

Deferred WPAFB/Keesler/Nellis David Grant/SAMMC

(5 years) (5 years) (6 years)
30 June 2015 30 June 2015 30 June 2016

IAW title 10, not eligible for

deferment upon USUHS
USAFA/USUHS graduation
29 June 2027 29 June 2028
12 years ADSC
IAW title 10, not eligible for
deferment upon USUHS
AFROTC/USUHS graduation
29 June 2026 29 June 2027
11 years ADSC

USAFA/AFHPSP 29 June 2024 29 June 2024 29 June 2025

9 years ADSC

AFROTC/AFHPSP 29 June 2023 29 June 2023 29 June 2024

8 years ADSC
IAW title 10, not eligible for
deferment upon USUHS
USUHS graduation
29 June 2022 29 June 2023
7 years ADSC

**AFHPSP (4yrs)) 29 June 2019 29 June 2019 29 June 2021

**AFHPSP (3 yrs) 0R 29 June 2018 29 June 2019 29 June 2021

AFHPSP (2 yrs) 3 yr
MTOS

Notes:
** Incurs additional ADSC for sponsored training
1. In the event incurring additional ADSC is a consideration factor for you, DO NOT rank programs that will result in
extending your current obligation
2. Ranking programs indicates you are willing to incur the additional ADSC as indicated above for the sponsored training.
3. Reminder, you will be required to enter training if you rank and are selected for training programs approved by the
JSGMESB.

Active Duty Tours (ADT’s) and Interviews

All applicants must complete an Active Duty Tour (ADT). The active duty tour in a clinical specialty enables you to
meet the JSGMESB interview requirement provided you interview in person with the program director in your
number one training location and specialty choice preference. Upon arrival at your active duty tour location please
be sure to schedule an appointment with your program director for a face to face interview. If you apply for a
different training location or specialty choice other than where you completed your active duty tour, you will need
to complete an interview (preferably in person) with one active duty (Air Force) Program Director in that specialty.
Applicants applying to Neurosurgery must interview with the Air Force Neurosurgery Consultant as there is no Air
Force Active Duty Program. All medical students completing an ADT can receive a possible maximum of 3
additional points toward their overall JSGME score.

NOTE: In the event the Program Director is deployed, a interim Program Director will be appointed. Ensure you contact either
the program director or his/her designee if program director is deployed.
 HPSP
Moonlighting
In accordance with the Department of Defense Policy and AFI 44-102 applicants are not authorized for off-
duty employment, i.e. “moonlighting,” during the GME training. Obligated Air Force officers are required to
comply with all Department of Defense and Air Force regulations. In some instances these requirements vary
from non-obligated Air Force peers.

Licensure Policy
Individuals selected for PGY1 only must take Step 3 and provide DPAME a passing score by
15 March 2011. Please plan accordingly as different states have different requirements and refer to the testing
websites for the upcoming schedules and registration requirements: MD’s: http://www.usmle.org/ and DO’s:
www.nbome.org. Please plan accordingly to allow sufficient time for study and receiving test results (up to 6
weeks). Individuals selected for a categorical residency must possess a current, valid, unrestricted state
medical license before completion of their 2nd post graduate year.

Reporting to active duty training

Each of the military residency programs has an extensive orientation to assist you with your transition to the
active duty military and to prepare you for your residency program. Mandatory report dates are usually in early
June. Accommodations can be made for trainees whose medical school completion date conflicts with the
report date, otherwise trainees are required to report on the assigned date. Please plan accordingly.

After Residency
If selected for training by the JSGMESB, physicians will be required to work in a clinical capacity (in the
specialty to which they trained) for two years after GME completion, unless the Air Force Surgeon General
waives this requirement due to the needs of the AF mission.

Reserve Component Health Risk Assessment (RCHRA)

The Reserve Component Health Risk Assessment form will be provided to you by AFIT. It must be
completed by your applicant’s primary care provider (a fully licensed M.D. or D.O.). Current residents, fellow
medical students, nor family members who are physicians will meet this requirement. Completed RCHRA
must be returned to the following address no later than
4 Septemeber 2009:

AFIT/ENEM
2275 D Street
Bldg 16, Room 120
Wright Patterson AFB. OH 45433-7221

NOTE: RCHRA must be sent to AFIT only. Sending the RCHRA to DPAME will cause unnecessary delays
in obtaining AETC/SG’s medical disposition.

AFIT will forward the RCHRA to HQ AETC/SG to determine a final medical disposition. In some instances,
HQ AETC/SG may need additional medical documentation in order to make a final determination. Submitting
this documentation in a timely manner is important.

Medical clearance by HQ AETC/SG is a requirement prior to the board convening. Applicants not medically
qualified prior to meeting the JSGME board could possibly be non-selected for residency training and receive a
PGY 1 only in Transitional Medicine, Internal Medicine or General Surgery.

Section II: Required Elements for the HPSP GME Application

Please read all instructions before completing any part of the application. Applicants must comply with
all requirements if they wish to be considered for GME selection.

All elements of the GME application must be typed. No handwritten documents will be accepted by the GME
board. Mail the following documents to:
Graduate Medical Education Selection Board
HQ AFPC/DPAME
550 C Street West Ste 27
Randolph Air Force Base, Texas 78150-4729
 HPSP

General information
a. Submitted application materials are for JSGMESB and DPAME use only. Copies will not be furnished to
the applicant or other agencies. Please plan accordingly if/when applying to or accepting offers from civilian
institutions that requires a separate application process. Applicants are reminded they should keep a copy of
their application package (if scheduled to be away from home for any reason), DPAME will not provide
applicant’s, interviewers or other agencies a copy.

b. Applicants are strongly encouraged to submit the 2-page DOD application immediately; the remaining core
application documents can follow by the 4 September 2009 deadline. This will enable DPAME to identify the
applicant’s intentions of applying to the JSGMESB and generate an itemized checklist for the applicant.
Applications received in July and August will have a quicker turn-around time (less than 1 week) than
applications received in September. If the applicant waits until the deadline week to submit the core
application then it will take DPAME 2 to 3 weeks to generate an initial checklist.

c. Program Directors are strictly prohibited from hand-carrying GME applications or supporting
documentation to the board. Please ensure the original application is received by DPAME on or before
4 September 2009. Please do not delay in sending an application, late applications may result in the
selection of a PG1 only year. Please be advised that overnight Federal Express may not guarantee that
documents will arrive overnight or in 24 hours, as it will be delivered to up to 2 additional places prior to being
received by DPAME.

d. Supporting application documents not received at HQ AFPC/DPAME by 5 October 2009 may not be
considered by the JSGMESB.

e. Please print application and supporting documents on plain, white bond paper. Do not print the
documents on front/back. Forms must be placed in specific areas in the application file and the front/back
feature will not allow for separating the documents.

f. This is a Tri-Service Board, all forms must be standardized when downloading from your email or the
AFMS website. Do not change, alter, or deviate from the original format including the Curriculum Vitae.
If you have any questions or comments, please feel free to contact the Medical Student Program Manager, at
(210) 565-0656, DSN 665-0656 or 800-531-5800, extension 1.

CORE APPLICATION must arrive to DPAME NLT 4 September 2009* and consists of:
1. DOD JSGMESB Application (submit the 2 page application as soon as possible) Must print on 2 pages
2. PG1 Only Form
3. Curriculum Vitae (CV)
4. Personal Essay
5. Education Summary
6. 2nd Choice Form
7. Statement of Understanding
8 Voluntary Disclosure Statement
* Please note, ensure that you meet the application deadlines. Late application may not be considered for
your specialty of choice.
Contact Information
Applicants should notify DPAME of any changes in contact information to ensure timely receipt of documents
and application status. In order to expedite notifications and delivery, DPAME sends electronic checklists to
applicants regarding application status. The applicant is able to include up to 3 email addresses with the
application to ensure timely receipt of notifications.

DOD Application
a. The DOD application and supporting documents must be typed and printed on one side only on plain white
bond paper.

b. This form is being used by ALL participating services – Air Force, Army and Navy. Most items are self-
explanatory. Complete sections 1 through 15.

c. Item 12 must reflect your first specialty training choice only. If you have a second choice, indicate this in
the appropriate block on the Second Choice Form enclosed. It is important to note that Requests for Change in
 HPSP
Specialty will only be accepted between 14 Sep 09 through 13 Oct 09 if the desired specialty is still open for
those additional 30 days.

e. Items 17 & 18 are self-explanatory. Please provide AFPC/DPAME copies of the official USMLE or
NBOME - Steps 1 and 2 scores once you have received them. The checklist provided to you by DPAME upon
receipt of your application will reflect which, if any, of these are required. Items 19 and 20 are not applicable.

f. Item 23a - TNG PREFERENCES. As an Air Force applicant, you are approved to request up to a
maximum of 6 location preferences. Note the difference between applying for Deferred or Civilian Sponsored
status (please see section I for detailed descriptions of training statuses).
Important note: Even if an applicant is requesting civilian deferment or civilian sponsorship as their
first training preference, medical students must rank at least one active duty location and interview with
their first choice active duty program director. Applicants are encouraged to rank all active duty
locations to maximize selection and placement opportunities. Please provide supporting documentation
explaining why you chose deferment over active duty programs if needed, otherwise use the last
paragraph of your essay to explain this.

PG1 only form (due 4 September 2009) This form has two parts:
Part 1. Applicants not selected for either the first or second choice for categorical residency training must
indicate to the Selection Board if they wish to be considered for a one year active duty program or not.
Applicants are not required to rank all three PG1 specialties for active duty programs but should only
numerically rank the programs they are interested in. When making a selection of Internal Medicine, General
Surgery or Transitional, don’t forget to rank order the location preference below each PG1 numerically.
Applicants who do not wish to be considered for one year of training at an active duty location, indicate this in
item one, and, unless applying for a pre-select specialty, sign and date the page.

Part 2. Individuals applying for a pre-selected position at an active duty location must indicate what
preliminary year they would like to do. Please number the choices. Example of pre-selected specialties are
Radiology, Neurology, Anesthesiology, Ophthalmology and Urology. Individuals pre-selected for training
will be given a preliminary year at the same location as the specialty training.

Curriculum Vitae (CV)

The applicant is required to use the GME format. Your application meets a tri-service board and must be
standardized. Please follow this format exactly. Do not modify (i.e. change fonts/pitch, remove dividing
lines, re-arrange sections, etc.) or your CV may be returned for corrections. If a section does not apply to
you, example “military spouse” then put “N/A” under that section, but do no delete it.

Personal Essay
Required from all applicants; must be no more than 1 page (double spaced, Times New Roman, 10-12 Font,
and with 1 inch margins). Essays not following this format will be returned for correction. The Selection
Board is greatly influenced by this essay. Using a three to four paragraph concept, outline specific
personal/professional plans and goals, why you want to train in a particular specialty, and what strengths you
bring to that specialty. If the applicant has any extenuating circumstances for the board to consider,
please briefly list in the last paragraph. Examples of extenuating circumstances are marriage to a member
of the Air Force or another service (copy of marriage license and spouse’s orders will be required); spouse is in
a training program not affiliated with the Air Force (copy of marriage certificate and statement from training
program required), parent with a terminal illness or spouse/child with special medical needs (medical
documentation from treating physician with a diagnosis and prognosis required), etc. Individuals should also
mention extenuating circumstances during their interview. This is your opportunity to communicate with the
board members: Do Not Waste It!

Education Summary
Data requested is supplementary information to that of the DOD Application Form. It is self-explanatory.
Additional instructions are on the form. Ensure you complete this entire document. If you don’t know your
 HPSP
security clearance then leave this area blank and we will complete this for you. It must be included as part of
your core application.

Second Choice Form

This form must be filled out by all applicants and requires a signature. Second choice refers to specialty only.
If applicants do not have a second choice for specialty, no further action is required after filling out item 1 and
signing. Completion is mandatory.

Statement of Understanding
Read, sign, and date this page. Signature is mandatory

Voluntary Disclosure Statement

This form is required to be submitted to DPAME, however disclosure is voluntary. The information on this
form is used for statistical analysis only.

SUPPORTING DOCUMENTS consists of:

1. USMLE/COMLEX Step 1
2. USMLE/COMLEX Step 2 (Clinical Knowledge)
3. Deans Letter
4. Official Copy of Medical School Transcript
5. Two personal Letters of Recommendation
6. Weight Statement
7. Program Director Interview

Current, Personal Letters of Recommendation

Letters must be originals with original signatures written/dated within the current calendar year (2009). Letters
from previous applications will not be used and have been discarded. Carefully consider who will submit a
letter of recommendation. If the applicant submits more than two letters, the first two letters received will be
used and the extra letter(s) will be discarded. Do not request more than two individuals to send in letters and
later requests to “switch out” letters will not be granted. Faxed letters will not be accepted.

USMLE/COMLEX Scores
Applicants must include a copy of Step I and Step II of the USMLE or COMLEX with the application. Step II,
Clinical Knowledge (CK), is mandatory for the GME application. You must take Step II CK by 15 September and
submit a copy to DPAME no later than 23 October 2009. Keep in mind that it takes up to 6 weeks to receive
results. If students fail either step of the exam, they must submit a copy of the test scores for full
disclosure and provide the date they are scheduled to retest. Note: See www.usmle.org or
www.nbome.org for current examination schedules and fees.
Note: Selection for a full length residency is contingent upon passing Step II, CK.

Official Medical School Transcript (due 9 November 2009)

The official transcript must be sent from the school directly to DPAME.

Dean’s Letter (due 9 November 2009)

The official Dean’s Letter must be sent from the school directly to DPAME. Medical School Deans nationally
release the official Dean's Letter on 1 November 2007 for all medical students. Applicants should insure that a
Dean's letter is sent to HQ AFPC/DPAME for inclusion in the application. This document is extremely
important to the application.

Many schools mail the Dean's Letter and transcript at the same time. This is acceptable; however, applicants
may wish to have the transcript mailed separately to ensure it is included in the application package for the
selection panel to review. Absence of these documents may result in the selection panel having insufficient
information to select individuals for full specialty training. It is the applicants’ responsibility to make sure the
Dean's Letter and transcripts have been received in this office no later than 9 November 2009.

Weight Statement (Weigh in 5 - 9 October 2009 and submit NLT 13 October 2009)
All applications must contain the weight statement. THIS IS NOT A VOLUNTARY DISCLOSURE
STATEMENT. Weight must be certified by ROTC unit personnel, active duty medical facility, MTF or health
 HPSP
services at the medical school. If applicable, please attach a copy of the Body Fat Measurement (BFM). If the
applicant is unable to comply with these dates, please contact DPAME for guidance. Be sure the certifying
official signs and dates the statement. Please include the office symbol and location with phone numbers of
the place where the test was taken. Please refer to this website if you would like to know the Air Force weight
and body fat standards: http://usmilitary.about.com/od/airforcejoin/a/afmaxweight.htm

DOD (Air Force Program Director) Interview

This form is not included with this package, as it has already been forwarded to all Air Force Program
Directors/Consultants. The intent of the interview sheet is for Program Directors to assess the applicant’s
qualifications for selection in the requested specialty.

It is MANDATORY that all applicants contact at least one active duty Air Force program director in the
specialty they are applying for to complete a 30 day active duty tour prior to 27 October 2009. You must
complete one active duty tour with the program director at the first active duty location preference for your
specialty of choice. Interviews will not be conducted via telephone unless the program director and
AFPC/DPAME authorize it. Be sure to schedule a face to face interview with the program director upon
arrival at the active duty tour. In addition, applicants are REQUIRED to send a copy of the 2-page DoD
application and CV (only) to each Air Force program director in the specialty for which applying. (In the
event that additional documentation is requested by the program director, individuals should contact
DPAME. The program directors have been advised that applicants are only authorized to provide the
CV and 2-page DoD application). All application documents will be provided to the program directors at the
time of the JSGMESB. Providing the 2-page DoD application and CV is extremely important, even if
applicants desire to train in a deferred location. Keep in mind, the program directors are the board members
who will be selecting individuals for specialty training and location. The more familiar he/she is with
applicant’s desires at the time the board meets, the better chance the applicant has of getting what they want.
A list of directors of medical education and program directors can be found on this web site as well at the
following link (please note, due to Privacy Act regulations, names are not posted on the website, however, the
contact information will direct applicants to the appropriate person):
http://www.airforcemedicine.afms.mil/afphysicianeducation

If the applicant has made attempts to contact the appropriate person and is having difficulty, please contact
DPAME for assistance at 1800-531-5800, Extension 1.
 HPSP

Section III: 2009 JSGMESB Application Forms

Notes:
1. It is strongly recommended to mail this form in first (as soon as possible), but no later than deadline of
4 Sept 2009. Once this form is received, your program manager can begin processing your application, and email your
GME checklist to you.

2. Ensure your name/social security number is listed the top of page 2 of the JSGMESB application.

3. Remember to print all application documents on white bond paper, one side only. Documents that are printed on
front/back will be returned without action.

4. Please do not alter or delete sections of the CV. All sections are required, even if it does not apply to you. If a section,
such as military spouse, does not apply, please enter N/A.

5. Contact DPAME for assistance/guidance at (800) 531-5800 ext 1, (210) 565-0656, or DSN 665-0656.
 HPSP
DEPARTMENT OF DEFENSE APPLICATION FOR GRADUATE MEDICAL EDUCATION
THIS FORM IS AFFECTED BY THE PRIVACY ACT OF 1974

1 AUTHORITY: 10 USC 3012.

2 PRINCIPAL PURPOSE(S): To compile information necessary to evaluate an application for military graduate medical education (GME) training.
3 ROUTINE USES: To evaluate application for professional training in military and civilian facilities (Medical Corps officers only).
4 MANDATORY OR VOLUNTARY DISCLOSURE: Disclosure of requested information is voluntary, however, without it, consideration for GME cannot be accomplished and GME may
not be assured.

1. NAME (Last, First, MI) 2. GRADE 3. SSN 4. CURRENT SPECIALTY 5. SERVICE

0-1 MEDICAL STUDENT Air Force
Army

Navy

6. HOME ADDRESS (ZIP+4) 7. HOME PHONE 8. MED SCHOOL ADDRESS 9. MED SCH PHONE
(with Area Code) CML:

FAX:

7. CELL PHONE Pager:

10. EMAIL:
11. CURRENT STATUS 12. SPECIALTY OR SUBSPECIALTY REQUESTED
MEDICAL STUDENT HPSP ROTC/ Ed Delay Choice:
ACTIVE DUTY PGY1 (INTERN)
ACTIVE DUTY RESIDENT
ACTIVE DUTY FELLOW 13. START DATE REQUESTED 14. PROGRAM LENGTH
ACTIVE DUTY FIELD/OPERATIONAL/STAFF
DEFERRED/REDEF/FAP (Until Month/Year) ( ) YEAR (S)
OTHER (Specify)
15. TRAINING
a. Undergraduate School COMPLETION OR GRAD YEAR
Major

Approximate GPA Honors

b. Medical School Name COMPLETION OR GRAD YEAR

Approximate GPA Class Ranking______ of ______ School Does Not Rank____

Academic Honors

16. MEDICAL LICENSING EXAMINATIONS (Copy of Steps/Levels 1-3 must be submitted with this application)
Check One Circle One
Step/Level 1 Passed Failed Year taken______ Not Taken
Step/Level 2 Passed Failed Year taken______ Not Taken FLEX NBME/USMLE NBOME/COMLEX
17. ECFMG (If applicable) Certificate # N/A Date

Validated/Approved by JSGMESB Committee May 2009

 HPSP

NAME (Last, First, MI)

18. Participation in Federally Funded Programs (check all that apply):

HPSP ROTC or Ed delay USUHS FAP Military Academy Direct Accession

19. TRAINING PREFERENCES

Rank order 1, 2, 3, etc.
AIR FORCE ARMY
David Grant Medical Center, Travis AFB, CA Eisenhower Army Medical Center, Fort Gordon, GA
Eglin Regional Hospital, Eglin AFB, FL Madigan Army Medical Center, Tacoma, WA
Erhling Bergquist Hospital, Offutt AFB/University of Nebraska, NE NCC-Walter Reed Army Medical Center, Washington, DC/
Keesler Medical Center, Keesler AFB, MS Dewitt Army Community Hospital, Fort Belvoir, VA/
National Naval Medical Center, Bethesda, MD,
NCC-/National Naval Medical Center, Bethesda, MD/Walter Reed Army USUHS
Medical Center, Washington, DC/Dewitt Army Community Hospital, Fort
Belvoir, VA, USUHS
SAMMC, San Antonio Military Medical Center – Wilford
Hall/Brooke Army Medical Center
Mike O’Callaghan Federal Hospital, Nellis AFB, NV
SAMMC, San Antonio Military Medical Center – Wilford Hall/Brooke Army Medical
Center

Scott Medical Center, Scott AFB/St. Louis University, IL Tripler Army Medical Center, Honolulu, HI
Wright-Patterson Medical Center, Wright Patterson AFB/Wright State Univ, OH. William Beaumont Army Medical Center, El Paso, TX
USAFSAM, (RAM/HYPERBARIC ONLY) Brooks AFB, TX Womack Army Medical Center, Fort Bragg, NC
Civilian Sponsored Darnall Army Community Hospital, Fort Hood, TX
Civilian Deferred/Redeferred (Nonfunded) Martin Army Community Hospital, Fort Benning, GA
NAVY Keller Army Community Hospital, West Point, NY

Naval Medical Center, Portsmouth, VA Civilian Sponsored

Naval Medical Center, San Diego, CA Civilian Deferred (NGMEP)
Naval Hospital Bremerton, WA OTHER
Naval Hospital, Camp Lejeune, NC Uniformed Services University of the Health Sciences
(Non-Clinical)
Naval Hospital, Camp Pendleton, CA
Naval Hospital, Jacksonville, FL Armed Forces Institute of Pathology
Naval Hospital, Pensacola, FL Walter Reed Army Institute of Research
Naval Aerospace Medical Institute, Pensacola, FL Other Federal (indicate Institution)
Civilian Navy Sponsored (FTOS)
Navy Sponsored
NCC-National Fulltime
Naval Outservice
Medical Center,(FTOS) Civilian
Bethesda, GME Reed Army Medical Center, Washington,
MD/Walter
DC/ Dewitt Army Community Hospital, Fort Belvoir, VA, Malcolm Grow Medical Center, Andrews
AFB, MD/USUHS

Civilian Deferred (NADDS)

20. I understand that the GME training received is directed toward board certification. I am familiar with the training requirements for board certification in the specialty
for which I have applied. It is understood that I must enter a program that is accredited and listed in good standing in the most current Graduate Medical Education
Directory published by the American Medical Association or if applicable (generally PGY1 level of GME) by the most current Yearbook and Directory published by the
American Osteopathic Association. I understand that I must also meet the requirements to sit for the certification examination by the respective specialty board which is
recognized by the American Board of Medical Specialties. For those subspecialties, which do not lead to board certification nor accreditation status, training must be
received in a program approved by the appropriate specialty society. I understand that my service obligation following schooling will be computed in accordance with
applicable Service regulation and DoD Directives and that I will be made aware of my exact obligation prior to entering GME training. I acknowledge that I understand
the contents of this application and I affirm that the information given in this application is true and complete to the best of my knowledge. I am aware that I must submit
all supporting documents required by the military Service for which I am assigned for this application to be complete.

APPLICANT SIGNATURE : DATE:

Validated/Approved by JSGMESB Committee May 2009

 HPSP

Curriculum Vitae
MM/DD/YYYY

PERSONAL DATA

Full Name: Grade:

SSN: Corps: Service:
__________________________________________________________________________
Current Home Address:

Home Phone:

Pager:

Cell Phone:

Email:
____________________________________________________________________________
Medical School

Phone:
Commercial:
Pager: Ext:

Email:
_____________________________________________________________________________
Birth Date: City of Birth:
State of Birth: Country of Birth:
_____________________________________________________________________________
Spouse: (Complete the following only if your spouse is active duty)

Full Name: ,
SSN:
Service: Corps:
Duty Assignment: Other:
______________________________________________________________________________
EDUCATION:
Undergraduate:
Medical School:
Other Postgraduate:

Degree:
School:
Graduation Date:

Degree:
School:
Graduation Date:

Degree:
School:
Graduation Date:

Military Training Courses:

OBC OAC CGSC C4 C4-A Flight Surgeon Brigade Surgeon Course
 HPSP
Other Military Courses
_____________________________________________________________________________

PRIOR MILITARY SERVICE (Complete this section if you have had prior active duty military service, to include a staff physician
assignment within another branch of service or prior service before attending medical school, – chronological order starting with latest
Service)

Type of Service:
Rank:
Corps (commissioned Service only):
Description of Service (describe the type of duties performed):

Dates of Service: TO
__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.

Type of Service:
Rank:
Corps (commissioned Service only):
Description of Service (describe the type of duties performed):

Dates of Service: TO
__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.

Type of Service:
Rank:
Corps (commissioned Service only):
Description of Service (describe the type of duties performed):

Dates of Service: TO
__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.
___________________________________________________________________________
WORK HISTORY/MILITARY ASSIGNMENT HISTORY (If applicable) (Chronological order starting with current assignment or
civilian job going back no more than 5 years before the start of medical school):
Duty Title:
Duty Location:

Dates of Assignment: TO Present

__.__.__.__.__.__.__.__.__.__.__.__.__.__.__.
Civilian positions:
Employer:
Duties:
Dates of Employment:
______________________________________________________________________________
HONORS AND RECOGNITION:
Undergraduate:
Medical:
Military:

PROFESSIONAL SOCIETIES: (must indicate in what capacity completed i.e. medical student)

PUBLICATIONS/RESEARCH: (must indicate in what capacity completed i.e., medical student)

 HPSP

_________________________________________________________________________________________
EXTRACURRICULAR ACTIVITIES/VOLUNTEER WORK (Only cover 5 years before the start of medical school)

Position:
Employer:
Duties:
Dates of Employment
 HPSP

2nd Choice Form

This form is required by all applicants, whether or not an applicant has a second choice for specialty (Example: First
specialty choice is Internal Medicine, Second specialty choice is Family Medicine). If an applicant has only one choice
for specialty but wishes to list more than one placement preference, list this information on the second page of the 2-
page JSGMESB application.

(CHECK ONE)

1. _______ I do have a second choice for specialty/subspecialty training. (Complete items 2-5.)

_______I do not have a second choice for specialty/subspecialty training. (Do not complete sections 2-5.
Sign/date bottom of page)

2. If I am not selected for my first choice, I wish to be considered for the following as my second choice preference. I
have ranked my preference for training location for my second choice below. (Only applicable if I am NOT selected
for my first choice).

3. 2D CHOICE TRAINING REQUESTED

Specialty _____________________________________________________________

Program Length _______________years Start Date __________________

4. TRAINING PREFERENCES:- (Please rank order preference desired, with “1” being your first choice).

Nellis
NCC (DeWitt, Bethesda, Walter
David Grant Reed, USUHS) Wright Patterson
SAMMC San Antonio Military
Eglin Medical Center Keesler
Ehrling Bergquist Scott Navy
Deferred Civilian Sponsored Army

Please print:

________________________________ ________________________ _______________________

(LAST, FIRST, MI) (SSAN) (DATE)

SIGNATURE _____________________________________________

2nd Choice Form

 HPSP

PGY1 ONLY
If I am not selected for either my first or second categorical choice:

1. I do ____ wish to be considered for PG1 training at an active duty location. (Complete the following)

2. I do not ___ wish to be considered for PG1 training at an active duty location. (Sign/date bottom of page unless
you are applying for a pre-select specialty such as Radiology, Neurology or Anesthesiology)

PG1 ACTIVE DUTY LOCATION PREFERENCES

(Rank specialties (1, 2, 3) and then rank locations associated with specialty)

_________TRANSITIONAL _______INTERNAL MEDICINE _________GENERAL SURGERY

____David Grant ____ SAMMC San Antonio ____Wright-Patterson

Military Medical Center
____Keesler
____ SAMMC San Antonio
Military Medical Center ___David Grant

___SAMMC San
Antonio
Military Medical Center

3. I have applied for a specialty that requires a PG1 year in an active duty program and would like my
preliminary year to be in (Rank choices numerically, i.e., 1,2,3, as appropriate):

_________TRANSITIONAL _________INTERNAL MEDICINE _________GENERAL SURGERY

The preliminary year will be at the same location as your specialty training.

4. APPLICANT COMMENTS/REMARKS: (If applicable)

_____________________________________ _____________________ _______________________

(LAST, FIRST, MI) (SSAN) (DATE)

SIGNATURE:_________________________________________
 HPSP

Graduate Medical Education - Statement of Understanding

FOR MEDICAL STUDENTS ONLY

NAME (PRINT)________________________________________________________

a. I must have taken, passed and obtained the results of Step I and Step 2 of the USMLE/NBOME/COMLEX prior to meeting the
Joint Services Graduate Medical Education Selection Board (JSGMESB).

b. I must apply for one year of training or for a categorical program in a basic specialty in active duty status or in deferred status.

c. If I am selected in a categorical training program in an Air Force medical facility, I will not be required to apply for continued training in
the same training program. I further understand that if I am selected for an active duty program, I will withdraw from the National
Residency Match Program. I must possess a current, valid, unrestricted and unencumbered state medical license before completion of my
2nd post graduate year

d. If I am selected for full deferral to complete specialty training in a basic specialty, I will be deferred for the minimum period necessary to
complete eligibility for board certification. Additional deferment or change to another specialty will require an application to a future
JSGME Selection Board for consideration. I must possess a current, valid, unrestricted and unencumbered state medical license before
completion of my 2nd post graduate year.

e. If I am not selected for a full categorical program, I will be given one year of clinical post-graduate training only in internal medicine,
general surgery, or transitional medicine. If I do not apply for further training, or am not selected for further training, I will be released to
Physician Utilization Branch for an assignment as a General Medical Officer or a Flight Surgeon. I understand that I must take STEP 3 and
provide DPAME a passing score by 15 Mar 2011.

f. I understand that I will be required to work in a clinical capacity for a short tour (12 months) or a two-year stateside assignment
after completion of initial training, unless the AF/SG waives this requirement due to the needs of the AF mission.

g. In the event I am deferred for training I will only enter or accept training through the NRMP unless approved by the JSGMESB.

h. I understand that in accordance with the Department of Defense Policy and AFI 44-102 applicants are not authorized for off-duty
employment, i.e. “moonlighting,” during the GME training.

i. I understand that once I have entered training as approved by the JSGMESB, I will be unable to change training locations or
specialty training without Air Force approval. I will contact HQ AFPC/DPAME in the event circumstances (personal or academic)
changes occur.

j. I understand that I must contact DPAME in the event I am placed on academic notice or probation or my completion date changes
from the selection board approval date.

k. All medical students must obtain their Medical or Osteopathic Degree prior to being authorized to travel to residency training.

______________________________________ _____________________________ ______________________

(SIGNATURE) (SSAN) (DATE)
 HPSP

2009 Graduate Medical Education – Weight Statement

Must be completed by all applicants

MUST WEIGH BETWEEN 5 – 9 OCT 2009

AND SUBMITTED TO AFPC/DPAME NLT 13 OCT 2009

This information is NOT self-reporting. The statement must be signed and dated by a medical representative at your training facility, your
personal physician or OTHER medical personnel OTHER THAN YOURSELF. Your application will NOT be completed without this
certification.

PRINTED NAME

SSAN

HEIGHT (INCHES) WEIGHT

INFORMATION CERTIFIED BY
NAME TITLE, WORK PHONE #

SIGNATURE of Medical Representative and current date

Date________________.

If you are over your maximum allowable weight a body fat percentage is required. Body Fat%________.
 HPSP

RACE/ETHNIC VOLUNTARY DISCLOSURE STATEMENT

NAME____________________________________________________________________________
Indicate your sex and circle one choice in the race category as well as one choice in the ethnic category. This information is used for
statistical analysis only.
GENDER: ________MALE ________FEMALE

Race, (Circle applicable code, or list other at the bottom of the list) Code
ASIAN, BLACK/AFR AM, NAT HI/PACIFIC ISL, WHITE 1
ASIAN, BLACK/AFR AM, WHITE 2
ASIAN, NATIVE HI/PACIFIC ISL 3
ASIAN, NATI HI/PACIFIC ISL, WHITE 4
ASIAN, WHITE 5
BLACK, AFR AM, NAT HI/PACIFIC ISL 6
BLACK, AFR AM, NAT HI/PACIFIC ISL, WHITE 7
BLACK, AFR AM, WHITE 8
NAT HI/PACIFIC ISL, WHITE 9
AMERICAN INDICAN/ALASKA NATIVE A
ASIAN B
BLACK./AFRICAN AMERICAN C
NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER D
WHITE E
DECLINED TO RESPOND F
IDENTIFICATION PENDING G
AMER INDIAN/AK NAT, ASIAN H
AM INDIAN/AK NAT, ASIAN, BLACK/AFR AM J
AM INDIAN/AK NAT, ASIAN, BLACK/NAT HI/PACIFIC ISL K
AM IND/AK NAT,ASIAN,BLACK/ HI/PACIFIC ISL/WHITE L
AM INDIAN/AK NAT,ASIAN,BLACK/AFR AM,WHITE M
AM INDIAN/AK NAT,ASIAN,NAT HI/PACIFIC ISL N
AM INDIAN/AK NAT,ASIAN,NAT HI/PACIFIC ISL,WHITE P
AM INDIAN/AK NAT,ASIAN,WHITE R
AM INDIAN.AK NAT/BLK/AFR AM/NAT HI/PACIFIC ISL S
AM INDIAN/AK NAT,BLACK/AFR AM, WHITE U
AM INDIAN/AK NAT, NAT HI/PACIFIC ISL A
AM INDIAN/AK NAGT/NAT HI/PACIFIC ISL, WHITE W
AMERICAN INDIAN/ALASKA NATIVE,WHITE X
ASIAN, BLACK/AFRICAN AMERICAN Y
ASIAN BLACK/AFR AM, NAT HI/PACIFIC ISL Z
OTHER______________________________________________

PRIVACY ACT STATEMENT: AUTHORITY: Title 10, U.S.C., Section 8013, Secretary of the Air Force. PURPOSE: to
provide Department of Defense statistical analysis of the results of the GME selection board. ROUTINE USES: It will be used
by HQ AFPC/DPAME for statistical analysis only. DISCLOSURE: Furnishing this information is voluntary, however, without
it, accurate statistical analysis of the GME selection board cannot be accomplished.
 HPSP

2009 DOD APPLICATION EDUCATION SUMMARY – MEDICAL STUDENT

NAME GRADE SSAN

UNDERGRADUATE MEDICAL SCHOOL

USAFA USUHS
Dates sponsored (MM/YR) Dates sponsored (MM/YR)

AFROTC HPSP
Dates sponsored (MM/YR) Dates sponsored (MM/YR)

Civilian Civilian

AFROTC Educational Delay

Dates MM/YR

Name of educational institution Name of Civilian Medical School

OFFICER’S TRAINING COURSE (list attendance at COT, BOT, OTS, HPOIC, ROTC, USAFA, or None Attended)
Training Training Location Start/Stop Dates
(MM/YR)

SECURITY CLEARANCE

Security clearance yes Expiration date ________________ no Date initiated _________________

ACTIVE DUTY TOURS

Assignment Position Title Base/Location Dates (To/From)
MM/YR