Graduate Programs in HPE 24-25:

RCS: HA(X)XXXX
OMB# 0720-XXXX
Exp. XX-XX-XXXX

AGENCY DISCLOSURE NOTICE


The public reporting burden for this collection of information, OMB# 0720-XXXX, is estimated to average 24 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT


AUTHORITY: 10 U.S.C. 2113, Administration of University; 10 U.S.C. 2114, Students: selection; status; obligation; DoD Directive 6010.7, Admission Policies for the Uniformed Services University of the Health Sciences (USUHS); DoD Instruction 6010.20, Admission Procedures for the Uniformed Services University of the Health Sciences; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To allow the Uniformed Services University of the Health Sciences to review admission applications and select students. Also used as a management tool for statistical analysis, tracking, reporting, evaluating program effectiveness and conducting research.
ROUTINE USES: The applicable Routine Uses are listed in the Systems of Records Notice, WUSU 04, Applicant Records System Records, located at: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570617/wusu-04/.
DISCLOSURE: Voluntary; however, failure to provide the information may result in the inability to process an individual’s application.
Application for Graduate Programs in Health Professions Education

Identifying Information
Last Name*
First Name*
Middle

Suffix

Other Names Used

SSN*
 9 digits only

Date of Birth*
  (mm/dd/yyyy)

Country of Citizenship*


Address and Contact Information
Mailing Address*

(Continued)

City*
State / Province*

Country*

Postal Code*
+ 4


Work Address

(Continued)

City
State / Province

Country

Postal Code
+ 4


Primary Phone*
Number*
-

Please enter Area Code and number without dashes.

Secondary Phone
Number
-

Please enter Area Code and number without dashes.


Primary e-mail address must be your work e-mail address if you are a US government employee. US military personnel must use the .mil address.

Primary Email Address*

Secondary Email Address*


    required and     optional