Appendix 1
Proposed Application
Application for International Fellowship
Personal Information
Name:
Age:
Mailing address:
Street:
City:
State, Province, Local:
Country:
Email address:
Mobile phone:
Office phone:
Fax:
Family Status (NOT required, only voluntary information)
Spouse or Significant other name:
Children’s names and ages:
Current Professional Status
Your Title (e.g. Assistant Surgeon):
Specialty (e.g. Surgery, Orthopedics, Plastics):
Location:
(City and State, Province, or Local):
Country
Years at current position:
Chief surgeon or advisor at location:
Senior Surgeons or Mentors(past and present doctors who know youand who could serve as references; you did not necessarily have to train with this person). If possible, please list three. Additional names can be attached.Letters from AAHS member sponsors will also be accepted, although this is optional and not required.
- Name and Title:
Location:
Relationship (e.g. teacher, local doctor, educational activities):
- Name and Title:
Location:
Relationship (e.g. teacher, local doctor, educational activities):
- Name and Title:
Location:
Relationship (e.g. teacher, local doctor, educational activities):
Education
(if more than one in any category, then list primary and include others as attachments)
Undergraduate
Name of institution:
Location:
Dates attended:
Graduate
Name of institution:
Location:
Dates attended:
Medical School
Name of institution:
Location:
Dates attended:
Places of Training(since completing basic medical training; if needed, includeothers as attachments)
1.Name of institution:
Chief surgeon or advisor or mentor:
Location:
(City and State, Province, or Local):
Country
Dates of service:
2.Name of institution:
Chief surgeon or advisor or mentor:
Location:
(City and State, Province, or Local):
Country
Dates of service:
3.Name of institution:
Chief surgeon or advisor or mentor:
Location:
(City and State, Province, or Local):
Country
Dates of service:
4.Name of institution:
Chief surgeon or advisor or mentor:
Location:
(City and State, Province, or Local):
Country
Dates of service:
5.Name of institution:
Chief surgeon or advisor or mentor:
Location:
(City and State, Province, or Local):
Country
Dates of service:
Clinical and Surgical Responsibilities(brief descriptions of your recent activities, including an estimate of number of patients evaluated, medical conditions seen, e.g., trauma, arthritis, pediatric, reconstructive, number of operations performed annually, and types of procedures)
Outpatient:
Inpatient:
Surgical:
Teaching Responsibilities(brief description of your current lectures, clinical teaching rounds, and other educational activities)
Doctors:
Therapists:
Nurses:
Other Students:
Personal Goals to Achieve during this Fellowship (brief description, e.g., increase knowledge of various conditions, learn new surgical techniques, become friends with established surgeons, travel through the United States)
Career Goals(brief description of your professional goals for future clinical care in hand surgery, teaching, possible research or other academic activities, leadership positions in teaching programs or hospitaladministration)