1011
Derek Harwood-Nash
International Fellowship Application
820 Jorie Boulevard • Oak Brook, IL 60523 • (630) 368-3742 • ...
Indicate your language fluency: Languages I speak
Languages I read
Languages I write
Please give us your proposed dates fo...
HOST INSTITUTIONS AND SPECIALTY AREAS
RSNA DEREK HARWOOD-NASH INTERNATIONAL FELLOWSHIP 2010
Institution Specialty
Brown Un...
Institution Specialty
Nationwide Children’s Hospital
Columbus, Ohio
Pediatric Radiology, Pediatric Interventional,
Pediatr...
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Application Form

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Application Form

  1. 1. 1011 Derek Harwood-Nash International Fellowship Application 820 Jorie Boulevard • Oak Brook, IL 60523 • (630) 368-3742 • Fax: (630) 571-7837 ELIGIBLE APPLICANTS must have completed their formal radiology training (MD or equivalent) and have held a faculty position in an academic institution for no less than 3 and no more than 10 years. Please complete the form, save it to your computer and send it to dtokarski@rsna.org , preferably as a PDF attachment. The following documents are also required to complete your application. Signed documents are to be forwarded as PDF attachments, faxed, or mailed to arrive by the deadline. Deadline: July 1, 2010 • A copy of your curriculum vitae (please send this document as an e-mail attachment) • A letter from your home institution that describes what institutional needs will be met by study in North America • A letter from the national radiologic society of your country confirming current membership and/or attendance at its meeting in the past two years • An additional letter of reference (optional) • Proof of proficiency in English- a TOEFL or equivalent test score taken within the last two years. For applicants of countries where English is an official language, no TOEFL test is required, but the letter from your home institution must attest to your verbal fluency in English. • A documented list of academic productivity, research, and involvement in trainee education • A 500-word personal statement (see page 2) Please provide the following information: Last Name Degree: MD, PhD, Other First Name Mailing Address Date of Board Certification Name of Home Institution Institution Phone Fax Home Phone E-mail Date of Birth Name of Medical School Graduation Date Location of Residency Training Completion Date Location of Additional Training Completion Date Please indicate the medical societies to which you belong: Page 1 of 4
  2. 2. Indicate your language fluency: Languages I speak Languages I read Languages I write Please give us your proposed dates for the start and end of this fellowship course of study (in 2011): Start date Stop date I would like to study at the following institution(s) [if more than one, please list them in order of priority]: 1) 2) 3) Please indicate your area of special interest in radiology: Please briefly describe your responsibilities at your teaching institution: Name, address, and fax number for your department’s training director: Please give any other information you believe would assist the Committee on International Relations and Education in its selection: Provide a 500-word personal statement that covers the following points: • Specific educational needs and objectives that can be met only by a course of study in North America • Specific plans for using the knowledge and experience gained to benefit and improve the practice of radiology in your home institution and radiologic community Please note that your personal statement is an important part of your application Personal Statement: For further information, please contact: Diane Tokarski Manager: International Relations and Education Radiological Society of North America 820 Jorie Blvd • Oak Brook, IL 60523 (630) 368-3742 • Fax: (630) 571-7837 dtokarski@rsna.org This form is available online at: http://www.rsna.org/DHN Completed application forms, whenever possible, should be submitted as PDF attachments to Diane Tokarski dtokarski@rsna.org. The application will not be considered complete unless all supporting documents are received in one of the following formats: PDF attachments, faxes or hard copies, mailed to arrive by the July 1st deadline. Page 2 of 4
  3. 3. HOST INSTITUTIONS AND SPECIALTY AREAS RSNA DEREK HARWOOD-NASH INTERNATIONAL FELLOWSHIP 2010 Institution Specialty Brown University/Rhode Island Hospital Providence, Rhode Island Pediatric Imaging, Body Imaging, Vascular & Interventional Radiology, Ultrasound, Thermal Oblation Services, Emergency Radiology, Nuclear Medicine Brigham & Women's Hospital Boston, Massachusetts Abdominal imaging, Neuroradiology, Oncoradiology, MSK Imaging, Mammography Case Western Reserve University & University Hospitals Case Medical Center Cleveland, Ohio Abdominal Imaging, Thoracic Imaging, Nuclear Medicine, Mammography, MRI, Neuroradiology, Pediatric Imaging, Angio-Interventional Radiology, Musculoskeletal Imaging Children's Hospital Boston, Massachusetts Pediatric Neuroradiology, Pediatric Head & Neck Radiology, All Pediatric Subspecialties Children's Hospital of Philadelphia Philadelphia, Pennsylvania Pediatric Neuroradiology, Pediatric Thoracic and Abdominal Imaging, Pediatric Musculoskeletal Imaging, Pediatric Interventional Radiology Children’s National Medical Center Washington, D.C. Pediatric Radiology, Pediatric Ultrasound, Fetal Imaging, Pediatric Nuclear Medicine, Pediatric CT / MRI Columbia University Medical Center New York, New York Functional MRI, Neuroradiology, Pediatric Radiology, Nuclear Medicine / PET Duke University Medical Center Durham, North Carolina Cardiothoracic Imaging Emory University School of Medicine Atlanta, Georgia Abdominal Imaging, Neuroradiology Hahnemann University Hospital Philadelphia, Pennsylvania Neuroradiology, Ultrasound, Cross-Sectional Imaging Indiana University School of Medicine Indianapolis, Indiana Abdominal Imaging, Neuroradiology, Breast Imaging, Nuclear Medicine, Pediatric Radiology Johns Hopkins Hospital and University Baltimore, Maryland Pediataric Neuroradiology, High-end Pediatric MR Imaging, Pediatric Uroradiology, Pediatric Ultrasonography Lahey Clinic Burlington, Massachusetts Magnetic Resonance Imaging, Mammography, Nuclear Medicine & PET, Body Imaging Louisiana State University HSC Shreveport, Louisiana Interventional (non-vascular), Neuroradiology, Nuclear Medicine, Cross-Sectional Imaging Mallinckrodt Institute of Radiology St. Louis, Missouri Interventional Radiology Mayo Clinic Rochester, Minnesota Abdominal Imaging, Neuroradiology, Vascular Interventional Radiology, Nuclear Medicine, Thoracic Radiology Mount Sinai School of Medicine New York, New York ENT Radiology, Hepatobiliary Disease, Liver Cancer – Chemoembolization, Yttrium 90, Radiofrequency Ablations Mammography/Breast Imaging, Neuroradiology, Pediatric Radiology/Ultrasound, Vascular and Interventional Radiology Page 3 of 4
  4. 4. Institution Specialty Nationwide Children’s Hospital Columbus, Ohio Pediatric Radiology, Pediatric Interventional, Pediatric Ultrasound, Pediatric MR & CT, Pediatric Oncologic Imaging Thomas Jefferson University Hospital Philadelphia, Pennsylvania Diagnostic Ultrasound, MRI, MSK Radiology University of California, San Diego San Diego, California Musculoskeletal Imaging, Interventional Spine, Vascular & Interventional Radiology University of Florida Gainesville, Florida Cardiac Imaging University of Maryland Medical Center Baltimore, Maryland Thoracic & Cardiac Radiology, Trauma, Nuclear Medicine PET-CT, MSK, Abdominal University of Michigan Ann Arbor, Michigan Thoracic Radiology, Thoracic Cardiovascular CT and/or MRI University of Rochester Rochester, New York Ultrasound, Body MRI & CT, Photoacoustic Imaging University of Texas Southwestern Medical Center / Children’s Medical Center Dallas, Texas Pediatric Neuroradiology University of Virginia Charlottesville, Virginia Chest, Abdomen, Pelvis, CT, Body MR, Non-Vascular Invasive Procedures, Ultrasound Imaging Wake Forest University Winston-Salem, North Carolina Mammography/Women’s Imaging, Interventional Radiology Wayne State University / Detroit Medical Center Detroit, Michigan Pediatric Radiology, Neuroradiology, Trauma Radiology, Body Imaging William Beaumont Hospital Royal Oak, Michigan Neuroradiology, Vascular/Interventional Radiology, Breast imaging Page 4 of 4

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