Surgical Critical Care Fellowship Application

University of Colorado / Denver Health Medical Center

Please mail to:

Clay Cothren Burlew, MD FACS

Program Director, SCC and TACS Fellowships

Department of Surgery

Denver Health Medical Center

777 Bannock Street, MC 0206

Denver, Colorado 80204

(303-436-6558)

Name: Last First Middle / Social Security Number
Home Address City/Sate Zip
Telephone (Home): / Telephone (Hospital/School):
E-mail:
Birth date (mo-day-year) / Place of birth / Citizenship
If non-citizen, type of Visa held (exchange, visitor, immigrant, etc.) / Date of entry into US
Do you have any condition that might impair your participation in the program? If so, please describe.

EDUCATION

High
School / Name / From / To
Address
College / Name / From / To / Degree
Address
Medical
School / Name / From / To / Degree
Address
Graduate
School / Name / From / To / Degree
Address

TRAINING

Internship,
Residency
and
Fellowship / Hospital / From / To / Field
City and State
Hospital / From / To / Field
City and State
Hospital / From / To / Field
City and State
EXAMS / USMLE
Step 1 ______Step 2 ______Step 3 ______
ABSITE PERCENTILE
PGY 1 ______PGY II ______PGY III ______PGY IV ______


Honors:

Memberships in Professional Societies:

US Board

Certification
or
Eligibility /

Specialty Certified Date of Certification

or
Eligible
(circle one)

Specialty Certified Date of Certification

or
Eligible
(circle one)

Medical Licensure

State ______Year Issued ______

State ______Year Issued ______

CURRICULUM VITAE: Please attach your current CV, including publications. Please make sure each publication has the unique PMID number assigned to it and listed in PubMed included.

PERSONAL STATEMENT: Please attach a copy of your personal statement.

REFERENCES: Please list three (3) references, of whom one must be the Program Director at your current residency and

two (2) must be physicians who can render an evaluation of your professional and academic abilities.

Please have these recommendations sent directly to the address at the top of the first page.

Program Director: / Address:
Email address:
Other Recommendations: / Address:
Email address:
I certify that to the best of my knowledge, the above information is accurate and correct.
______
Signature Date