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Apply the highest standards of urological care
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
*
Excellent
Good
Moderate
Fair
Other Languages Spoken
*
Marital Status
*
Single
Married
Divorced
Widow/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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Application has been submitted successfully
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