THE CHILDREN’S HOSPITAL of PHILADELPHIA

3401 Civic Center Boulevard Philadelphia, PA 19104

APPLICATION FOR
PEDIATRIC HOSPITAL EPIDEMIOLOGY AND OUTCOMES RESEARCH TRAINING PROGRAM
Please attach / PLEASE DO NOT WRITE IN THIS SECTION
recent photo / Appointment
as:______
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From:______To:______

I hereby apply for appointment as a Graduate Medical Trainee at The Children’s Hospital of Philadelphia for 24 months, beginning July 1, 2018 (with vacation, depending on length of service, being provided at a time convenient to the hospital).

PLEASE ü APPOINTMENT DESIRED

____Clinical Fellow ____Research Fellow ____Other:______

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Full Name:______M.D.______M.B.B.S ______D.D.S.______D.O.______M.B.B.Ch. ______D.M.D.______

Present Address:______City:______State:______Zip:______Country:______Telephone:______Pager #______

E-Mail Address:______Fax No.:______Permanent Address:______

Place of Birth:______Date of Birth:______Married______Single______

Citizen of:______U.S. Social Security No.:______

U.S. Unrestricted Medical License (attach copy): Graduate Medical Training License (attach copy): State:______No.______State:______No:______State:______No.______State:______No:______

U.S. Licensing Exams passed (attach copy of scores for each exam):

ECFMG English______TOEFL_____Clinical Skills Assessment____ LMCC_____FLEX______

State Board_____FLEX 1______FLEX II_____NBME 1_____NBME II______NBME III_____USMLE 1_____ USMLE 2______USMLE 3______

INTERNATIONAL MEDICAL GRADUATES (attach copies of each document)

ECFMG Certificate No.______Type if Visa______Hold______Needed______

THE CHILDREN’S HOSPITAL of PHILADELPHIA

3401 Civic Center Boulevard

Philadelphia, PA 19104

PREMEDICAL EDUCATION:

Institution From To Degree

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MEDICAL EDUCATION:

Institution From To Degree

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HOSPITAL TRAINING (do not list rotations in medical school):
Hospital / Location / From / To / Degree

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POSTGRADUATE EDUCATION (organized courses only):

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SPECIAL TRAINING (not already listed, such as assistantships, practice, etc.)

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THE CHILDREN’S HOSPITAL of PHILADELPHIA

3401 Civic Center Boulevard

Philadelphia, PA 19104

BOARD CERTIFICATION

Year Specialty Name of Board Country of Issuing Board

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ADDITIONAL INFORMATION (such as publications, summer work, extracurricular activities):

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REFERENCES: Letters of recommendation concerning professional ability and personal qualifications must be sent

under separate cover directly to Holly Burnside at the Center for Pediatric Clinical Effectiveness, from at least four physicians, one of whom is your residency program or subspecialty fellowship director. References should preferably be under whom you have served or trained. Please ask letter writers to address your qualifications for PHEOT, and not the MSCE/MSHP program.

Letters of recommendation must be requested by the applicant. List references below:

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SIGNATURE OF APPLICANT:______DATE:______

Return to: Holly Burnside

The Children’s Hospital of Philadelphia

Center for Pediatric Clinical Effectiveness

Roberts Center for Pediatric Research, Room 11201

2716 South Street

Philadelphia, PA 19146-2305

267-426-7549

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