INFECTIOUS DISEASES OBSERVATIONAL PRECEPTORSHIP YEAR 2007
DIVISION OF INFECTIOUS DISEASES MASSACHUSETTS GENERAL HOSPITAL BOSTON, MASSACHUSETTS, USA
SELECTION PROCESS AND APPLICATION FORM Initial application is through the local, regional, or national sponsoring society or medical association. Finalists will then be asked to provide additional information to the Division of Infectious Diseases, Massachusetts General Hospital
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GENERAL INSTRUCTIONS
Application forms for the Infectious Diseases Observational Preceptorship at MGH must be completed by the applicant (a form filled in by any other person(s) is not acceptable).
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DIVISION OF INFECTIOUS DISEASES Massachusetts General Hospital
Infectious Dise ases Observat ional Preceptorship, Year 2007
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APPLICATION FORM
Biographical Information
Full Name: Last or Family Name First Name Middle Name Maiden Name
U.S. Social Security Number (if available):
-
-
I. D. Number :
_____________________________
Current Mailing Address: Number and Street Fax No.: City E- Mail Address: State ZIP Country
Permanent Mailing Address: Number and Street City State ZIP Country
Permanent Contact Address: Name Relationship Telephone Number
Country of Citizenship: Please attach complete CV or complete all information below: Academic History
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List all colleges, universities, and medical schools attended after secondary school, ending with most recent institution.) Please Do Not abbreviate names. Use an extra page if necessary Dates attended From/To (Month/year) Date Awarded Or Expected (Month/Year)
Name of Institution & Location
Major Field of Study
Name of Degree
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2. Training Experiences and Employment: (List chronologically all positions after completion of medical school , including training in internal medicine and infectious diseases, and ending with current or most recent institution.) Dates Type of Experience (Identify “Type”: Intern, Resident, Fellow, Faculty Appt. , Military, Practice, etc. Institution City & State/Country
3.
List academic awards and honors received:
4.
Prior or present research activities (please briefly describe these activities. Indicate when, where and with whom the work was done. Describe your role in the work. You may use a separate page, if necessary):
5.
List of publications (if any):
6.
Affiliation with Local, Regional, National, or International Academic Societies or Associations (and positions held, if any):
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7.
State your reasons for desiring a Infectious Diseases Observational Preceptorship at MGH. You may use a separate page if necessary.
8.
Specific plans after the Infectious Diseases Observational Preceptorship at MGH:
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Language proficiency and level of literacy (excellent, good, fair, none) Language (s) Reading Writing Speaking
Voluntary Information
Date of Birth (MM/DD/YY) :
Sex: Male
______
Female
Marital status:
Married
____
Single
____
Other
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Children: _________________________
Other dependents: ________________________________
Do you intend to have your family accompanying you:
Yes __________
No: _______________
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Have you ever applied for a visa to the USA?
Yes _______
No __________
If yes, have you ever been denied a visa by USA Immigration Authority?
Passport No: _____________________________ Date of Expiration: _______________________ Country of Issuance: ______________________
PLEASE READ THE FOLLOWING STATEMENT CAREFULLY BEFORE SIGNING YOUR APPLICATION
I understand that all application material submitted becomes the property of the Division of Infectious Diseases, Massachusetts General Hospital and is not returnable. I also understand that the Division of Infectious Diseases, Massachusetts General Hospital is not obligated to furnish me with duplicate copies.
I understand that the Division of Infectious Diseases, Massachusetts General Hospital will rely upon the Information submitted herein to determine my status for appointment and training eligibility. I authorize the Division of Infectious Diseases, Massachusetts General Hospital to verify the information I have provided. I understand that any omission of requested data may jeopardize my admis sion or subsequent academic standing in the Division of Infectious Diseases, Massachusetts General Hospital. I agree to notify the Division of Infectious Diseases, Massachusetts General Hospital of any changes in the information provided.
I certify that the information in the application is complete and correct to the best of my knowledge and belief. I acknowledge the submission of any false information is ground for rejection of my application, withdrawal of any acceptance offer, appointment evocation, or appropriate disciplinary action after appointment.
Signature
Date
Release for Reference. I release from liability and from any restrictions as to confidentiality or privacy all hospitals, schools, physicians, employers, individuals, agencies or organizations that provide information about me at the request of the Division of Infectious Diseases, Massachusetts General Hospital or its agents.
Signature
Date
Application materials should be sent to the local, regional, or national sponsoring society or medical association for initial screening. Finalists will be selected and requested to send additional materials, as noted on the next page.
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GENERAL INSTRUCTIONS
Application form for the Infectious Diseases Observational Preceptorship at MGH must be completed by the applicant (A form filled in by any other person(s) is not acceptable. In addition to the preceding materials, once an applicant has been selected for final consideration, the following documents will be required before any offer of appointment can be made: Four copies of recent photograph. (Within 6 months) Curriculum vitae (if not already provided) Photocopy of all certificates and awards obtained Two letters of recommendation. Recommendation letters must be prepared on institution letterhead and should be dated no more than one year prior to the application date Evidence of English proficiency Physician’s certification of general health
Once a candidate is selected as a finalist through the local, regional, or national authorized sponsoring society or medical association, the additional materials above, plus a copy of the application form should be submitted directly to the following address: Dr Samir Podder, PhD Director, Medical Marketing Innovara, Inc 21 Pray Street Amherst, MA 01002, USA Tel: +1-413-549 5888 Fax: +1-413-549 0666 Mail: Samir.podder@innovara.com
Special Instructions for International Visitors
An appropriate visa must be obtained prior to arrival in the US. Candidates for appointment holding temporary visas are bound by the restrictions placed on the institution by the State Department concerning the training of such persons. The applicant will be asked to provide the information necessary to complete form IAP-66, and the Division of Infectious Diseases, Massachusetts General Hospital/Partners Healthcare, Inc. will provide assistance in securing the appropriate visa.
NOTE: All application materials become the property of the Division of Infectious Diseases, Massachusetts General Hospital and will not be returned to the applicant. The Division of Infectious Diseases, Massachusetts General Hospital is not required to provide copies of these materials to relevant parties.
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