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Apply the highest standards of urological care
UMN-SIU Leo Fung Memorial International Pediatric Fellowship
*
Indicates required field. If 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
*
Could not find the language line "scholarshipform_research_interests"
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 …)
*
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
Please upload professional references
(formats accepted: Word, PDF, JPG)
*
Please upload a recommendation letter from the immediate supervisor at the home institution
(formats accepted: Word, PDF, JPG)
*
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