Introduction to Academic Radiology (Itar) Application

2016-2017 RSNA/APSA

INTRODUCTION TO ACADEMIC RADIOLOGY (ITAR) APPLICATION

First Name: / Middle Initial: / Last Name:

Gender: Age:

/ Race/Ethnicity:

Degree(s):

/ Department/Program (if MD/PhD student):
Institution/Medical School: / Expected Graduation Date:
Address: / Phone:
E-mail:
Are you currently a Member of APSA?
If so, at what level is your membership? (Associate Member, Full Member, etc…) / Yes / No
Are you currently a Member of RSNA? / Yes / No
If selected for the RSNA/APSA ITAR, will you be able to attend the RSNA Annual Meeting in Chicago, Illinois in December 2016? / Yes / No
After completion of your MD or MD/PhD Program, which medical discipline will you choose for residency?
Have you conducted a substantial research project during your training? / Yes / No
If yes, for how many months? / months
To which specific field of medicine and/or research would you label your project?
Are you currently involved in a research project? / Yes / No
If so, provide a brief description, if not, please describe your past research (300 word limit):
How many case reports have you authored or co-authored?
How many scientific abstracts have you authored or co-authored?
How many full length research publications have you authored or
co-authored that are indexed for retrieval?
*Please include a complete bibliography of all of your research publications of any type, any research awards and any research funding you have received in your attached NIH-style biosketch.
* If you have presented your research at any scientific conferences or seminars, please name those experiences here and indicate whether they were poster or oral presentations:
* Please explain how do you plan to integrate Radiology into your research, clinical and professional development and how you think you will benefit from the ITAR program (500 words or less):

Deadline date for submission: July15th, 2016

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