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  • 1. &SCIENCE August 1,2008 UNIVERSITY Dear Fellow Applicant, Department of Pediatrics Pediatric Cardiology Thank you for your recent inquiry to the Pediatric Cardiology Fellowship Training Mail code: CDRC-P 707 S.W. Garnes Street Program at Oregon Health & Science University. We are accepting applications Portland, Oregon 97239-2998 for one fellowship position in Pediatric Cardiology to begin July 2010. tel 503 494-21 92 fax 503 494-2824 www.ohsu.edu The Pediatric Cardiology Fellowship Program at OHSU is a three-year ACGME- accredited training program. We offer fourth year sub-specialty fellowships in echocardiography, interventional catheterization and adult congenital heart disease on a case-by-case basis. One of the outstanding strengths of our program is that we are able to tailor your training in a way that best suits your anticipated career direction while at the same time providing a solid, comprehensive foundation of the fundamentals required by the Sub-Board of Pediatric Cardiology. We are proud to produce exceptionally trained graduates with the skills and opportunities to become leaders in any aspect of the field. Please note the checklist of required components at the end of the application. We recommend thatayou complete your application by January lSt.For those selected for interview with our faculty, we will be in touch with you shortly after that date. We appreciate your interest in o w program. Please refer to our web-site www.ohsu.edu/som/ped/fel card.cfm for more information about our faculty, curriculum or fellowship program. If you have any other questions please don't hesitate to contact me or Jodi Leonard at the contact information below. Yours sincerely, Laurie Arrnsby, MD Jodi Leonard Pediatric Cardiology Fellowship Director Pediatric Cardiology Fellowship Coordinator Assistant Professor of Pediatrics Doernbecher Children's Hospital Doernbecher Children's Hospital Oregon Health & Science University Oregon Health & Science University leonarjo@ohsu.edu armsbyl@,ohsu.edu 503-494-2 194
  • 2. Please include Oregon Health & Science University your photo here. University Hospital & Affiliated Hospitals Portland, OR 97239 APPLICATION FOR: FELLOWSHIP in PEDIATRIC CARDIOLOGY for the training period beginning July 1, 2010 All questions must be answered in full. Please use a computer or print. 1. Name ____________________________________________________________________________________ Surname First Name Middle Name Maiden Name 2. Present address ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ City State Zipcode 3. Home address ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ City State Zipcode 4. E-mail address _______________________________________________ 5. Present telephone # ___________________________________________ 6. Date of Birth ________________________________________________ 7. Place of Birth _______________________________________________ 8. Country of Citizenship ________________________________________ 9. If not a US Citizen, list Visa type and number ____________________________________________ 10. ECFMG # (If appropriate) _______________________ Valid through _______________________ Education and Training: 11. College(s) or University(s): ____________________________________________________Dates Attended ________________ ____________________________________________________Dates Attended ________________ Date of Graduation ____________________________________Degree(s) _____________________ 12. Medical School (s): ____________________________________________________Dates Attended ________________ ____________________________________________________Dates Attended ________________ Date of Graduation ____________________________________Degree(s) _____________________ (1)
  • 3. Applicant Name: _______________________________________________ 13. Previous Internship: Hospital / Program _______________________________________ Service ____________________ Dates __________________________________________________ 14. Previous Residency: Hospital / Program _______________________________________ Service ____________________ Dates __________________________________________________ Hospital / Program _______________________________________ Service ____________________ Dates __________________________________________________ 15. Previous Staff Position(s) (if any): Hospital / Group _________________________________________ Service ____________________ Dates __________________________________________________ 16. Previous Fellowship(s) (if any): Hospital / Program _______________________________________ Service ____________________ Dates __________________________________________________ 17. USMLE Scores: Step 1 ________________ Step 2 ________________ Step 3 _______________ 18. Medical Licensure (States and Numbers):_______________________________________________ _________________________________________________________________________________ 19. Please include in your CV, or on a separate page:  Research experience, publications, special skills (One Page Limit)  Electives, foreign travel, special medical experiences (One Page Limit)  Honors  Major extracurricular interests Signature________________________________________ Date ___________________ (2)
  • 4. The following are required from each applicant: o One signed copy of this application o A letter of recommendation from the Dean of your Medical School, including dates of attendance o Medical School Transcript o A letter of verification from the Program Director(s) of prior residency training, including dates, location and verification of completion o Two letters of reference from faculty at your current training program or professional colleagues if not in training o Verification of any previous staff positions o Personal Statement to include future goals in medicine (1 page limit) o Curriculum Vitae, to include a brief description of: research experience, publications, special skills; electives, foreign travel, special medical experiences; honors; major extracurricular interests Please send all applications and letters to: Laurie Armsby, MD Pediatric Cardiology Fellowship Program Director Division of Pediatric Cardiology Oregon Health & Science University 707 SW Gaines Road, CDRC-P Portland, OR 97239-3098 Please send all questions, clarifications or inquiries to: Jodi Leonard Pediatric Cardiology Fellowship Program Coordinator Division of Pediatric Cardiology Oregon Health & Science University 707 SW Gaines Road, CDRC-P Portland, OR 97239-3098 (3)
  • 5. The National Institutes of Health requests documentation of our applicant pool for training grant applications – please see attached NIH personal data sheet. Completion is optional, but would be appreciated. PERSONAL DATA ON PRINCIPAL INVESTIGATOR/PROGRAM DIRECTOR The Public Health Service has a continuing commitment to monitor the operation of its review and award processes to detect—and deal appropriately with—any instances of real or apparent inequities with respect to age, sex, race, or ethnicity of the proposed principal investigator/program director. To provide the PHS with the information it needs for this important task, complete the form below and attach it to the signed original of the application after the Checklist. Do not attach copies of this form to the duplicated copies of the application. Upon receipt of the application by the PHS, this form will be separated from the application. This form will not be duplicated, and it will not be a part of the review process. Data will be confidential, and will be maintained in Privacy Act record system 09-25-0036, “Grants: IMPAC (Grant/Contract Information).” The PHS requests Social Security Numbers for accurate identification, referral, and review of applications and for management of PHS grant programs. Provision of the Social Security Number is voluntary. No individual will be denied any right, benefit, or privilege provided by law because of refusal to disclose his or her Social Security Number. The PHS requests the Social Security Number under Sections 301(a) and 487 of the PHS Acts as amended (42 U.S.C 241a and U.S.C. 288). All analyses conducted on the date of birth and race and/or ethnic origin data will report aggregate statistical findings only and will not identify individuals. If you decline to provide this information, it will in no way affect consideration of your application. Your cooperation will be appreciated. DATE OF BIRTH (MM/DD/YY) SEX/GENDER SOCIAL SECURITY NUMBER Female Male ETHNICITY 1. Do you consider yourself to be Hispanic or Latino? (See definition below.) Select one. Hispanic or Latino. A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.” Hispanic or Latino Not Hispanic or Latino RACE 2. What race do you consider yourself to be? Select one or more of the following. American Indian or Alaska Native. A person having origins in any of the original peoples of North, Central, or South America, and who maintains tribal affiliation or community attachment. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. (Note: Individuals from the Philippine Islands have been recorded as Pacific Islanders in previous data collection strategies.) Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to “Black” or African American.” Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Check here if you do not wish to provide some or all of the above information. PHS 398 (Rev. 05/01) Personal Data Form Page