DHN Application Form - Radiological Society of North America



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| |Derek Harwood-Nash International Fellowship Application | |

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|820 Jorie Boulevard ( Oak Brook, IL 60523 |

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|Deadline: July 1, 2013 |

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|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. |

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|Please email your completed application as well as the required documentation listed below to CIRE@. Signed documents may also be sent via email. |

|Alternatively, application materials may be sent via mail to the address noted above to arrive by the July 1 application deadline. |

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|A copy of your curriculum vitae |

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|A letter from your home institution that describes what institutional needs will be met by study in |

|North America |

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|A letter from the national radiologic society of your country confirming current membership and/or attendance at its meeting in the past two years |

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|An additional letter of reference (optional) |

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|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. |

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|A documented list of academic productivity, research, and involvement in trainee education |

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|A 400-word personal statement (see page 2) |

|Please provide the following information: |

|Last Name | |Degree: | |First Name | |

| | |MD, PhD, Other | | | |

|Mailing Address | |

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|Date of Board Certification | | |

|Name of Home Institution | |

| |Number of beds | |Number of radiology residents | |

|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 | |

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|Please indicate the medical societies to which you belong: |

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|How long have you held a faculty position in a teaching hospital? | |

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|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 2014): |

| Start Date | | End Date | |

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|I would like to study at the following institution(s) - [If more than one, please list them in order of priority]: |

|1) | |

|2) | |

|3) | |

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|Please indicate your area of special interest in radiology: | |

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|Please briefly describe your responsibilities at your teaching institution: |

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|Name, address, and fax number for your department’s training director: |

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|Please give any other information you believe would assist the Committee on International Radiology Education in its selection: |

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|Provide a 400-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 |

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|Please note that your personal statement is an important part of your application. |

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|Personal Statement: |

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| |This form is available online at: |

|For further information, please contact staff at: |Derek_Harwood-Nash_International_Fellowship.aspx |

|CIRE@ | |

| |The application will not be considered complete unless the application |

| |form and all supporting documents are received in one of the following |

| |formats: |

| |PDF attachments, emailed to: CIRE@ |

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| |Hard copies, mailed to arrive by July 1, 2013 |

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| |Radiological Society of North America |

| |DHN – Attention: Department of International Affairs |

| |820 Jorie Blvd |

| |Oak Brook, IL 60523 |

| |USA |

Host Institutions and Specialty Areas

RSNA Derek Harwood-Nash International Fellowship

|Institution |Specialty |

|Brown University/Rhode Island Hospital |Pediatric Imaging, Body Imaging, Vascular & Interventional Radiology, |

|Providence, Rhode Island |Ultrasound, Thermal Oblation Services, Emergency Radiology, Nuclear Medicine |

|Case Western Reserve University & University Hospitals Case |Abdominal Imaging, Thoracic Imaging, Nuclear Medicine, Mammography, MRI, |

|Medical Center |Neuroradiology, Pediatric Imaging, Angio-Interventional Radiology, |

|Cleveland, Ohio |Musculoskeletal Imaging |

|Children's Hospital of Philadelphia |Pediatric Neuroradiology, Pediatric Thoracic and Abdominal Imaging, Pediatric |

|Philadelphia, Pennsylvania |Musculoskeletal Imaging, Pediatric Interventional Radiology |

|Children’s National Medical Center |Pediatric Radiology, Pediatric Ultrasound, Fetal Imaging, Pediatric Nuclear |

|Washington, D.C. |Medicine, Pediatric CT / MRI |

|Columbia University Medical Center |Functional MRI, Neuroradiology, Pediatric Radiology, Nuclear Medicine / PET |

|New York, New York | |

|Emory University School of Medicine |Abdominal Imaging, Neuroradiology |

|Atlanta, Georgia | |

|Hahnemann University Hospital |Neuroradiology, Ultrasound, Cross-Sectional Imaging |

|Philadelphia, Pennsylvania | |

|George Washington University Medical Center |Pediatric Imaging |

|Washington, D.C. | |

|Georgia Health Sciences University |Neuroradiology |

|Augusta, Georgia | |

|Indiana University School of Medicine |Abdominal Imaging, Neuroradiology, Breast Imaging, Nuclear Medicine, Pediatric |

|Indianapolis, Indiana |Radiology |

|Johns Hopkins Hospital and University |Pediatric Neuroradiology, High-end Pediatric MR Imaging, Pediatric Uroradiology,|

|Baltimore, Maryland |Pediatric Ultrasonography |

|Lahey Clinic |Magnetic Resonance Imaging, Mammography, |

|Burlington, Massachusetts |Nuclear Medicine & PET, Body Imaging |

|Louisiana State University HSC |Interventional (non-vascular), Neuroradiology, |

|Shreveport, Louisiana |Nuclear Medicine, Cross-Sectional Imaging |

|Mayo Clinic |Abdominal Imaging, Neuroradiology, Vascular Interventional Radiology, Nuclear |

|Rochester, Minnesota |Medicine, |

| |Thoracic Radiology |

|Mount Sinai School of Medicine |ENT Radiology, Hepatobiliary Disease, |

|New York, New York |Liver Cancer – Chemoembolization, |

| |ttrium 90, Radiofrequency Ablations |

| |Mammography/Breast Imaging, Neuroradiology, |

| |Pediatric Radiology/Ultrasound, Vascular and Interventional Radiology |

|Nationwide Children’s Hospital |Pediatric Radiology, Pediatric Interventional, |

|Columbus, Ohio |Pediatric Ultrasound, Pediatric MR & CT, |

| |Pediatric Oncologic Imaging |

|Thomas Jefferson University Hospital |Diagnostic Ultrasound, MRI, |

|Philadelphia, Pennsylvania |MSK Radiology |

|University of California, Irvine |Emergency Radiology, Cardiovascular and Thoracic Radiology |

|Irvine, California | |

|University of Florida |Cardiac Imaging |

|Gainesville, Florida | |

|University of Maryland Medical Center |Thoracic & Cardiac Radiology, Trauma, |

|Baltimore, Maryland |Nuclear Medicine PET-CT, MSK, Abdominal |

|University of Miami/Jackson Memorial Hospital |Abdominal Imaging, Interventional Radiology, Musculoskeletal Radiology, |

|Miami, Florida |Neuroradiology, Traum/Emergency Radiology |

|University of Michigan |Thoracic Radiology, |

|Ann Arbor, Michigan |Thoracic Cardiovascular CT and/or MRI |

|University of Rochester |Ultrasound, Body MRI & CT, Photoacoustic Imaging |

|Rochester, New York | |

|University of Texas MD Anderson Cancer Center |Vascular and Interventional Radiology, Body Imaging, Thoracic Imaging, Breast |

|Houston, Texas |Imaging, Musculoskeletal Imaging, Neuroradiology |

|University of Texas Southwestern Medical Center / Children’s |Pediatric Neuroradiology |

|Medical Center | |

|Dallas, Texas | |

|University of Virginia |Chest, Abdomen, Pelvis, CT, Body MR, |

|Charlottesville, Virginia |Non-Vascular Invasive Procedures, Ultrasound Imaging |

|University of Wisconsin School of Medicine and Public Health |Abdominal imaging, Community, MR and Chest, Neuroradiology, Musculoskeletal, |

|Madison, Wisconsin |Breast Imaging, Nuclear Medicine, Cardiovascular Imaging, Pediatric Imaging, |

| |Interventional, Imaging Sciences |

|Wake Forest University |Mammography/Women’s Imaging, |

|Winston-Salem, North Carolina |Interventional Radiology |

|Yale University School of Medicine |Body Imaging |

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Updated: December, 2012

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