THE CHILDREN'S HOSPITAL

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					Dear Applicant,

Thank you for your interest in the Children’s Hospital Boston Pediatric Cardiology Fellowship Training
Program. The following information is required in order to be considered for a categorical First Year or
Senior Fellowship position in our Program. Application questions can be directed to Stephen Ciano by
Phone: (617) 355-2706 or Email: stephen.ciano@childrens.harvard.edu


      Completed fellowship application. (ERAS for categorical fellowship. Senior Fellowship
      Application is below)

      Current Curriculum Vitae listing all educational activities by month and year

      Personal Statement

      Medical School Transcript which indicates courses taken, dates and hours of attendance,
      scores, grades, or evaluations. A translation must be provided if in a language other than
      English.

      Medical School Dean’s Letter and/or Performance Evaluation

      Three letters of recommendation.

      Three reference forms completed by the same recommendation letter writers. Our
      reference form is the last page of this document. NOTE: this form cannot be
      submitted through ERAS. First Year categorical applicants will need to ensure the
      form is emailed directly to: stephen.ciano@childrens.harvard.edu

      Copies of United States Medical Licensing Exam (USMLE) scores or Medical Council
      of Canada (MCC) scores.

      ECFMG Certificate if you are a graduate of a medical school outside of the United
      States or Canada
First Year Fellowship Positions:

      Please visit the Electronic Residency Application Service (ERAS) website to apply for a
       categorical fellowship position. http://www.aamc.org/students/eras/

      Deadline for completed applications is December 31st for positions starting on July 1st of the
       following year (18 months later).

      Interview season is January 15th to April 15th of each year.

      Selection is made through the National Resident Matching Program (NRMP). Please visit their
       website at www.nrmp.org for registration information.



Senior Fellowship Positions:

      Please use the following application and mail all required material to:

                              Department of Cardiology - Fellowship Program
                              Children’s Hospital Boston
                              300 Longwood Avenue
                              Boston, MA 02115

      Deadlines for completed applications:
          o Non-invasive Imaging fellowship is September 15th for positions starting on July 1st of
              the following year. Applicants are strongly encouraged to have their applications in
              before August 31st.
          o All other senior fellowships are October 1st for positions starting on July 1st of the next
              year.

      Interview season:
           o Non-invasive Imaging is September 1st to October 15th each year.
           o All other senior fellowships are October 1st to November 30th.

      Selection is made by:
           o November 1st (Non-invasive Imaging).
           o December 31st (all other senior fellowships).
                                                                 Senior Fellowship Application
                                                                   Department of Cardiology
                                                                      Children's Hospital Boston
                                                                       300 Longwood Avenue
           Attach photo here                                             Boston, MA 02115

                                                      If possible, please complete this application on your computer before
                                                       you print.
                                                      Please sign and attach your photo prior to sending.
                                                      Use the tab key to navigate through fields.

APPLICANT INFORMATION


First Name                             Middle                        Last Name                          Credentials/Degree(s)


Current Street Address                 City                          State                              Zip/Postal Code


     -     -                                  -    -
Home Phone                             Cell Phone                                                       Country


     -     -                                  -    -                       -     -
Hospital Phone                         Pager                         Fax



Work Email                                                           Personal Email


     - -                                  / /                                M        F
Social Security (U.S. only)            Date of Birth (mm/dd/yyyy)    Sex



Race (optional)                        Ethnicity (optional)          Citizenship                        Place of Birth



Permanent Street Address               City                          State                              Zip/Postal Code
(if different from above)


                                                                                                        Country

OTHER INFORMATION

1.   Please confirm that you are applying for advanced training as a Senior Clinical Fellow?       YES                   NO

2.   Please indicate dates of potential training: (mm/dd/yyyy)                            /   /   to    /    /
3.   Please indicate specialty area of training:

4.   If you are the recipient of a Fellowship, Stipend, or other Professional Grant please provide the following information
     as well as a certified letter (in English) from your donor stating the amount of your funds.


Donor Name                                                          Amount of Support

From:     / /        To:   / /                                      Has amount actually been awarded?
Duration of Support (mm/dd/yyyy)                                       YES      NO
UNDERGRADUATE, MEDICAL SCHOOL AND POST GRADUATE EDUCATION

(Medical School Transcript and Performance Evaluation/Dean’s Letter are required)


                                                                                                     /   /    to      /   /
Institution                                                             Degree/Position          Dates (mm/dd/yyyy)


City                                                                    State                    Country

                                                                                                     /   /    to      /   /
Institution                                                             Degree/Position          Dates (mm/dd/yyyy)


City                                                                    State                    Country

                                                                                                     /   /    to      /   /
Institution                                                             Degree/Position          Dates (mm/dd/yyyy)


City                                                                    State                    Country

                                                                                                     /   /    to      /   /
Institution                                                             Degree/Position          Dates (mm/dd/yyyy)


City                                                                    State                    Country

Please explain any gaps in education in the box below:




INTERNATIONAL MEDICAL GRADUATE

1.     If you are a graduate of an international medical school (except Canada), you are required to be certified by the
       Educational Commission for Foreign Medical Graduates (ECFMG). Please provide a copy of your ECFMG certificate.

2.     If not a U.S. citizen, what type of visa will you hold while you are here?

3.     Do you hold permanent immigrant status in the United States?                       YES                NO
           If yes, please attach a copy of green card or approval letter.

              National Identification Number                                      Country of Issue

4.     If you are in the United States on an Exchange Visitor Program, please provide name of your present sponsor.



5.     Are you currently in the Untied States on a Temporary Visa (i.e. J-1, H-1, F-1)?         YES          NO
           If yes, attach a copy of your current DS-2019 (if applicable).
MEDICAL LICENSURE AND EXAMINATIONS
1.      Please list your medical license information in the below.

                                                    /    /                                      Permanent/Full          Limited
State                     Number                  Expiration Date (mm/dd/yyyy)


                                                    /    /                                      Permanent/Full          Limited
State                     Number                  Expiration Date (mm/dd/yyyy)


                                                    /    /                                      Permanent/Full          Limited
State                     Number                  Expiration Date (mm/dd/yyyy)


2.      Have you taken the United States Medical Licensing Examinations (USMLE)?
        (Complete section below. Copies of results are required.)

            Step 1              YES         NO          Score =                 Date Passed (mm/dd/yyyy)       /   /
            Step 2 (CK)         YES         NO          Score =                 Date Passed (mm/dd/yyyy)       /   /
            Step 2 (CS)         YES         NO          Score =                 Date Passed (mm/dd/yyyy)       /   /
            Step 3              YES         NO          Score =                 Date Passed (mm/dd/yyyy)       /   /

Please explain any “NO” answers in box below.




3.      If you are a Canadian Medical Graduate, please provide copies of Medical Council of Canada (MCC) scores.

LETTERS OF RECOMMENDATION AND REFERENCE FORMS
MEDICAL LICENSURE
           Please list the name, title and full address of three people who will write letters of recommendation and complete a
            reference form (attached) on your behalf.
           It is required that one recommendation letter and reference form be completed by the Department Chairman and/or
            Program Director.
           It is strongly recommended that one recommendation letter and reference form be written by a pediatric cardiologist
            familiar with your work.



Name                                                                    Title


Street Address                             City                         State/Country                 Zip/Postal Code



Name                                                                    Title


Street Address                             City                         State/Country                 Zip/Postal Code



Name                                                                    Title


Street Address                             City                         State/Country                 Zip/Postal Code



APPLICANT'S SIGNATURE                                                                     DATE (mm/dd/yyyy)
                                                                                                                          Version 06-10
                                       CHILDREN’S HOSPITAL BOSTON
                                   CARDIOLOGY FELLOWSHIP PROGRAM
                                          REFERENCE FORM


Name of Applicant                                                                     Date     /     /
                                                                                             (mm/dd/yyyy)
Relationship to Applicant (check one)
   Program Director         Dept/Division Chair        Advisor        Clinical Preceptor           Research Preceptor

  Other

Compared to other residents at a similar level going on to sub-specialty training that you have supervised and have been the
preceptor over the past five years, how would you rate this applicant? Please check the boxes that most closely represent
your opinion of the applicant.

                               1                2                3                4                5                 6
            Skill          Below Avg.        Average         Very Good       Outstanding       Superlative        Unable to
                           Lower 50%        Upper 50%        Upper 20%       Upper 10%         Upper 5%            judge
                                                                                                                   please use
                                                                                                                 comment box
                                                                                                                below to explain

Overall Clinical Ability

  Interpersonal Skills

   Intellectual Skills

 Potential as a Clinical
     Cardiologist

 Potential for Research

      Leadership


Additional Comments




Signature                              Name (Print)                           Title

				
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