Fellowship period: July 1, 2016 - June 30, 2018

Application Due Date: May 1, 2015

Instructions:

Please complete this document in Microsoft Word and e-mail as an attachment to along with a curriculum vitae and research proposal/statement as described below. PLEASE INCLUDE ALL DOCUMENTS IN ONE E-MAIL.

·  Recommendation letters should be e-mailed directly from the letter writers to

·  Applicants will be notified once their file is complete.

·  Please e-mail us with any questions:

Application Checklist

PLEASE INCLUDE ALL COMPONENTS IN ONE EMAIL. THE APPLICATION, SUPPORTING DOCUMENTS, AND LETTERS OF RECOMMENDATION MUST BE RECEIVED BY THE DUE DATE.

1.  Application form

2.  Curriculum vitae or resume

3.  Research Plan/Personal Statement

4.  Any additional supporting documentation

Contact Information

Last Name

First Name

Address

City/State/ZIP Code

Phone Fax /
Date of Birth

Age

E-mail

Pager

Current PGY Level
Residency Information

Institution 1

Dates Attended

Address

City/State/ZIP Code

Phone Fax /
Institution 2

Dates Attended

Address

City/State/ZIP Code

Phone Fax
Education

Medical School

Dates Attended Degrees Earned

Address

City/State/ZIP Code

Phone Fax /
College

Dates Attended Degrees Earned

Address

City/State/ZIP Code

Phone Fax

Other Graduate School

Dates Attended Degrees Earned

Address

City/State/ZIP Code

Phone Fax /
Other Graduate School

Dates Attended Degrees Earned

Address

City/State/ZIP Code

Phone Fax
Research Plan/Personal Statement- 1500 Word Limit
In a separate Microsoft Word document, please describe your research interests, your career aspirations, and how the SOQIC research fellowship will help you achieve your goals. Include your prior research experience, any advanced research degrees, and any relevant statistical, epidemiologic, or programming experience. A specific research project does not need to be outlined here, but please note if you have specific research interests. Please include the Research Plan/Personal Statement in the application e-mail as an attachment and email to .
Curriculum Vitae

In a separate document, please include your curriculum vitae or résumé. E-mail as an attachment to

Please be sure to include

1.  Publications (full citations) 3. Awards / Honors

2.  Presentations (specify oral or poster; full citations) 4. Previous grants / research funding

Miscellaneous

Yes No

1. Are you a US Citizen?

If not, are you authorized to work in the United States?

(Please explain in a separate statement)

2. Have you ever been convicted of a felony?

If yes, please attach letter explaining the circumstances

3. Have you ever had a medical license revoked or suspended?

If yes, please attach letter explaining the circumstances

Letters of Recommendation

Please provide two letters of recommendation. Letter writers should e-mail the letters to .

Letter 1: Surgery Department Chairman: This letter should comment on applicant’s character, potential, abilities, and career plan. In addition, the Chairman must guarantee to the Selection Committee that the resident will be able to suspend his or her residency for two years to participate in the SOQIC fellowship.

Letter 1: Contact Information for Chairman

Last Name

First Name

Address

City/State/ZIP Code /
Degree and Title

Institution

E-mail

Phone

Letter 2: Previous Research Mentor, Program Director, or Other Faculty Surgeon. This letter should comment on the applicant’s character, abilities, potential, and career plan.

Letter 2: Contact Information for Other Reference

Last Name

First Name

Address

City/State/ZIP Code /
Degree and Title

Institution

E-mail

Phone

Surgical Outcomes and Quality Improvement Center (SOQIC) Research Fellowship Application Page 4 of 4