Application for Fellowship in Simulation Medicine

Application for Fellowship in Simulation Medicine Mayo Clinic Multidisciplinary Simulation Center College of Medicine Jacksonville, Florida  Rochester, Minnesota  Scottsdale, Arizona  Tel Aviv, Israel

Supporting Documents Required

☐ Curriculum Vitae – Describe your activities with professional societies, publications, and any other relevant information about your education or experience

☐ Personal Statement of Professional Goals

☐ Copy of Medical School Diploma or Graduate Education Diploma

☐ Copy of completion certificate from each of your prior residency and/or fellowship training programs

☐ Three letters of recommendation from physicians or faculty members who are thoroughly familiar with your work. If you have had prior residency training, ask your program director for a letter of recommendation. Each letter should include the writer’s opinion of your professional, academic, and personal qualifications, as well as an opinion of your potential success in simulation medicine.

Personal Data
Name Credentials

(Last) (First) (Middle)

Date of Birth SSN

(mo/da/yyyy) (US SSN only)

Current Home Address

(Street)

(City) (State) (Zip Code) (Country)

Work Phone Cell Phone
Email


Disclosure
☐Yes ☐No Have you, under this name or any other name, ever been convicted of a crime (felony or misdemeanor including DUI/DWI/OWI)?

If yes, please describe:

(Note to all applicants: You are not required to disclose information concerning convictions that have been annulled, expunged, impounded, sealed, pardoned, or statutorily eradicated. A criminal conviction will not constitute an automatic bar to admission, but will be considered in the context of the specific program(s) for which you have applied. However, falsifying your application by omitting information will be grounds to bar admission.)

☐Yes ☐No Have you ever been reprimanded, censored, placed on probation, or otherwise disciplined by, or have you ever been subject to a corrective action agreement/plan with any licensing board, school or residency or training program?

If yes, please describe:

☐Yes ☐No Is your professional license currently being investigated?

If yes, please describe?

Prior Education (attach additional pages if needed) List Degrees
to

(mo/yyyy) (mo/yyyy) (Undergraduate School)

(Address)

to

(mo/yyyy) (mo/yyyy) (Graduate School)

(Address)

(Major Professor Name) (Date PhD Awarded)

(Title of Master’s Thesis)

(Title of Doctoral Dissertation)

to

(mo/yyyy) (mo/yyyy) (Medical/Dental School)

(Address)

to

(mo/yyyy) (mo/yyyy) (Residency)

(Institution)

(Address)

to

(mo/yyyy) (mo/yyyy) (Fellowship)

(Institution)

(Address)

Other Experience

In chronological order, account for all other time from awarding of medical school diploma to present; give nature of experience and location. Include military service, if applicable. Attach additional pages if necessary.

to

(mo/yyyy) (mo/yyyy) (Institution / Location / Position)

to

(mo/yyyy) (mo/yyyy) (Institution / Location / Position)

to

(mo/yyyy) (mo/yyyy) (Institution / Location / Position)

Examination

Examination endorsement you will use to obtain medical/dental license and/or ECFMG certification?

Step 1	Exam	Number Times Taken	Date Passed
Step 2 CS	Exam	Number Times Taken	Date Passed
Step 2 CK	Exam	Number Times Taken	Date Passed
Step 3	Exam	Number Times Taken	Date Passed

International Medical Graduates

If you are a graduate of a medical school outside the United States or Canada, have you been certified by the Educational Commission for Foreign Medical Graduates (ECFMG)?

☐ Yes ☐ No ☐ Not applicable

ECFMG/USMLE Number ECFGM Certification Date

(mo/da/yyyy)
Letters of Recommendation

Three original letters of recommendation from physicians or faculty members who are thoroughly familiar with your work. If you have had prior residency training, ask your program director for a letter of recommendation. Each letter should include the writer’s opinion of your professional, academic, and personal qualifications, as well as an opinion of your potential success in the field for which you are applying.

Name of individuals who will write recommendation letters:

1. 
   
   
2. 
   
   
3. 
   
   

Applicant’s Certification

I certify all the information I have provided is complete and accurate.

(Applicant Signature) (Date – mo/da/yyyy)

Optional Information
Citizenship / Visa Notice
Will you need assistance with a non-immigrant visa? ☐ Yes ☐ No
If yes, country of citizenship Birthplace

(Country, city, and state or province)

If currently in United States, type of visa you now hold


Demographic Information (check all that apply)

☐ Hispanic	☐ Asian	☐ Native Hawaiian or US Pacific Islander	☐ American Indian / Alaskan Native
☐ Central American ☐ Cuban ☐ Mexican, Mexican-American, Chicano / Chicana ☐ Puerto Rican ☐ South American ☐ Other Spanish culture or origin regardless of race (except Spain)	☐ Cambodian ☐ Chinese ☐ Filipino ☐ Indian ☐ Japanese ☐ Korean ☐ Laotian ☐ Pakistani ☐ Taiwanese ☐ Thai ☐ Vietnamese ☐ Other Asian, specify	☐ Hawaiian ☐ Guamanian or Chamorro ☐ Samoan ☐ Other US Pacific Islander, specify	☐ African American ☐ American Born African ☐ African ☐ Caribbean Black ☐ Other black, specify
☐ Non-Hispanic	☐ American Indian / Alaskan Native	☐ White	☐ Female
	Specify Tribe/ Community:		☐ Male

Multidisciplinary Simulation Center – Page

Application for Fellowship in Simulation Medicine