SIU scholarship program questionnaire 

Family Name *

First Name(s) *

Title *

Date of Birth (YYYY-MM-DD) *

Photo *

Nationality *

Native Language *

Mailing Address

Telephone (Country Code, Area Code & Number):

E-mail Address *

English Proficiency * ExcellentGoodModerateFair

Other Languages Spoken *

Marital Status * SingleMarriedDivorcedWidow/Widower

Number of Children *

Profession and current employment of your partner *

Hobbies (sports, culture) *

What are your future expectations and plans after the scholarship? Will you stay in academics, will you return to the Institution you are currently working in? *

How did you hear about the SIU Scholarship Program (who told you)? *

Membership in medical associations and societies. Positions held (if any) *

Details of Institution applying to *

Time Period *

Currently employed at *

Status and Function *

What specifically is the aim of your scholarship in clinical and experimental urology?  *

Envisioned source of funding *

Do you have other funds (or scholarships) available? If so give details *

Expected total expenses during scholarship *

Is your family joining you? *

If not, who is going to support them at home?  *

School Attended *

Diploma Obtained *

Year *

University Attended *

Degree Obtained *

Year *

M.D. *

Ph.D.

Training since graduation (List all previous employers to date) *

Describe the Institution you are currently working in

Institution you are currently working in *

Program Director *

Number of Faculty Members *

Number of Residents *

Main areas of interest – clinically & experimentally *

Number of urological surgical procedures performed per year in your department

TURP *

TURB *

Nephrectomy *

Cystectomy *

Urinary Diversion (list specific procedures) *

Radical Prostatectomy *

Ureteroscopy *

Pediatric urology procedures (hypospadias, antireflux etc.) *

Special procedures *

Describe special areas of clinical expertise in your hospital (e.g. bilharzia, tuberculosis, ureteral disease, trauma, vesico-vaginal fistulae, extensive stone disease …) *

Describe your main areas of interest and clinical and experimental experience

Clinical

Experimental

Ultrasound

Percutaneous Nephrostomy

Urodynamics

Andrology

Pediatric Urology

Oncology

Endoscopy

List the number of following procedures performed by yourself to date

Major procedures (cystectomy, radical prostatectomy, urinary diversion) *

Large procedures (e.g. nephrectomy) *

TUR Prostate *

TUR Bladder *

Endoscopy *

Minor cases (e.g. hydroceles, circumcisions) *

Pediatric cases (antireflux proc., hypospadias) *

Special Procedures *

Your publication list (most recent first) *

Personal Statement: Describe your qualifications and reasons for seeking this fellowship.

Detailed CV *

Letter of acceptance from the host institution *

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