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Apply the highest standards of urological care
UCSF-SIU Research Fellowship
If any required field is not applicable, please write "N/A".
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 fellowship? Will you stay in academics; will you return to the Institution you are currently working in?
*
How did you hear about this Fellowship (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
*
Research Interests that would guide the selection of your assignment under this program. Specifically, in which area of urology would you want to do research for this fellowship?
*
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
*
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
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
Professional References
*
Proposed Area of Study
*
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