LoyolaUniversityMedicalCenter
Surgical Critical Care Fellowship
1
Surgical Critical Care Fellowship
LoyolaUniversityMedicalCenter
Application
For Academic Year 2014-2015
General Information:
Name (last, first)______
Previous last name______
Date of Birth______
Place of Birth______
Citizenship______
Social Security Number______
Home Address______
______
Home Telephone______
Business Address______
______
______
Business Telephone______
Business Fax______
Email______
EDUCATION
Undergraduate______
______
Degree______
MedicalSchool______
______
Degree______
POSTGRADUATE TRAINING
Internship______
______
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Residency______
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BOARD CERTIFICATION / ELIGIBILITY
USMLE______
Board Certification______
EXAMINATIONS
Examination / Percentile Score / Outcome / Date(s)USMLE Step 1
USMLE Step 2
USMLE Step 3
ABSITE PGY-1
ABSITE PGY-2
ABSITE PGY-3
ABSITE PGY-4
ABSITE PGY-5
MEDICAL LICENSURE
ACLS:Exp. Date:
PALS:Exp. Date:
ATLS:Exp. Date:
ABLS:Exp. Date:
DEA Reg #:______
Medical Licensure Problem?Reason: ______
Ever named in a malpractice suit?Reason: ______
STATE MEDICAL LICENSES:
Type / Number / State / Expiration DateEducation Commission for Foreign Medical Graduate Certification
Are you certified by the ECFMG?
Certification Date:
AWARDS AND HONORS:
AWARD / DATEMEDICALSCHOOL
RESIDENCY
OTHER
MEMBERSHIP IN HONORARY OR PROFESSIONAL SOCIETIES
WORK EXPERIENCE
Organization / Position / Dates / Description / Reason for leavingRESEARCH EXPERIENCE:
Organization / Dates / Supervisor / DescriptionPUBLICATIONS:
LANGUAGE FLUENCY
HOBBIES AND INTERESTS
CERTIFICATION
I certify that all information in this application is true and no material omissions have been made
Certified by:Date:
Application Procedure
1.If you have not already submitted one, we would like to receive your recent curriculum vitae.
2.We would like to receive up to Three (3) letters of recommendation directed to the Program Director of the Fellowship Program.
3.Please submit a brief summary of your special interests and plans for the future.
4.Return above materials along with application to:
Hieu Ton-That, MD
Program Director, Surgical Critical Care Fellowship
Loyola Univ. Med. Ctr. Dept. of Surgery
2160 South First Avenue
EMS 110, Room 3279
Maywood, IL60153
Phone: (708) 327-2680 Fax: (708) 327-3489
Email:
All candidates must be registered through the National Resident Matching Program. Personal interviews are conducted in July, August and September of each year. The deadline for applications is early October 10thand the Match results become available at the end of October or early in November. More information about training in the Surgical Critical Care Program can be found at the American Board of Surgery website:
In addition, the fellow must be able to obtain a permanent medical license in the State of Illinois and be legally able to accept employment. For those requiring a visa to work, Loyola University is able to accept J-1 visa sponsorship only. For those selected to interview, a day-long visit is scheduled at which time the candidate will meet with the Program Director, Division Director, Surgical Critical Care faculty, and other members of the Surgical Critical Care team including nurses, pharmacists, social workers, dieticians, etc. A rank order list of fellowship candidates is determined by the Program Director with input from others taking into consideration the letters of support, personal interview, career goals, and credentials and experience of the candidate. This list is then submitted to the NRMP and the results are announced in late October or November. If a position remains after the Match, the process continues. The final selection of a fellow is determined by the Program Director with input from others.