THE UNIVERSITY OF TEXASHEALTHSCIENCECENTER AT SAN ANTONIO

Division of Child Abuse Pediatrics

Department of Pediatrics

7703 Floyd Curl Drive

San Antonio, Texas78229-3900

APPLICATION FOR CHILD ABUSE FELLOWSHIP to start ______

(Year fellowship to start)

Full Name: ______/ M.D. ___ / D.O. ___ / Other (describe) ______
Present Address:______
City:______/ State:______/ Zip:______/ Country:
Telephone:______/ Beeper #: ______
E-Mail Address:______/ Fax No.:______
Permanent Address (if different from present address):______
City:______/ State:______/ Zip:______/ Country:
Place of Birth:______/ Date of Birth:______
Citizen of:______/ U.S. Social Security No.:______
U.S. Unrestricted Medical License and /or Graduate Medical Training License (please fax copy of attach pdf file):
State:______
State:______/ No.______
No.______/ State:______
State:______/ No:______
No:______
U.S. Licensing Exams passed (circle all that apply and fax copy or attach as pdf for each relevant examination):
ECFMG ______/ TOEFL ______/ Clinical Skills Assessment ____ / LMCC ______
English ______/ FLEX ______/ FLEX 1 ______/ FLEX II ______
State Board ______/ NBME 1 ______/ NBME II ______/ NBME III ______
USMLE 1 ______/ USMLE 2 ______/ USMLE 3 ______
International Medical Graduates(please fax copy of attach pdf file)
ECFMG Certificate No.______Type if Visa______Hold______Needed______
Premedical Education
Institution / Location: City, state
(include country if not USA) / Dates of Attendance
(mm/yy – mm/yy) / Degree or area of study
(e.g., Biochemistry)
Medical Education
Institution / Location: City, state
(include country if not USA) / Dates of Attendance
(mm/yy – mm/yy / Degree or area of study
(e.g., Medicine)
Hospital Training (e.g., internship, residency, etc.)
Institution / Location: City, state
(include country if not USA) / Dates of Attendance
(mm/yy – mm/yy / Degree or area of study
(e.g., Pediatrics)
Other Education(if relevant, e.g., masters degree, doctoral degree)
Institution / Location: City, state
(include country if not USA) / Dates of Attendance
(mm/yy – mm/yy / Degree or area of study
(e.g., Masters of Public Health)
Special Training or Experience(if relevant and not already listed, such as assistantships, practice, etc.)
Board Certification(if any)
Year / Specialty (e.g., Pediatrics) / Type of Board / Country of Issuing Board (if not USA)
Additional Information(if relevant, such as publications, summer work, extra curricular activities or may attach a resume or CV)
References: Communications concerning professional ability and personal qualifications must be sentunder separate cover directly to Nancy Kellogg, MD, The Division of Child Abuse Pediatricsat TheUniversity of Texas Health Science Center at San Antonio from at least three individuals, preferably under whom you have served ortrained. Letters of recommendation must be requested by the applicant. List references below.
Name of Person and Degrees(if any) / Nature or Relationship (e.g., program director)
  • Please attach recent photo (electronic preferred).
  • Please feel free to provide additional materials or add additional lines to this form.
  • Please attach a one page summary about your interest in child abuse pediatrics as a career. This might include personal experiences, research activities that you have undertaken, mentors that have influenced you, etc.

For additional information, please feel free to contact:

Nancy Kellogg, MD at 210-704-3939 or

To fax any materials, please fax to:

Attention: Child Abuse Fellowship Program 210-704-3392 or

Scan application, supporting documents and photos to:

Nancy Kellogg, MD at

To mail any materials, please mail to:

Nancy Kellogg, MD

Child Abuse Fellowship Program

315 North San Saba

Suite 201

San Antonio, Texas78207