ALLERGY & IMMUNOLOGY TRAINING PROGRAM SECONDARY APPLICATION

FOR FELLOWSHIP BEGINNING JULY 1, 2013

 

  

Department of Internal Medicine                                                    

Division of Allergy and Immunology                                              

University of South Florida College of Medicine                         

Veterans’ Medical Clinic (111D)                                                    

13000 Bruce B. Downs, Blvd                                                           

Tampa, FL 33612                                                                                                                                                 PHOTO

 

Contact Person (USF/Internal Medicine):         

Geeta Gehi                                                           

Tel: (813) 972-7631                                              

E-mail: ggehi@health.usf.edu                       

  

                                                                                                                            

                                                                                                            

ONLY APPLICANTS WHO HAVE COMPLETED BOTH THE ERAS APPLICATION (https://www.erasfellowshipdocuments.org) AND THIS SECONDARY APPLICATION WILL BE CONSIDERED.  Acceptance of applications, inlcuding supporting materials, will close on August 15, 2012 for the July, 2013 fellowship position.  Please answer all the questions (no exceptions) and please include an updated Curriculum Vitae).

 

Note:  There are two distinct USF Allergy/Immunology programs: one in Internal Medicine and one in Pediatrics.  This application is for the Internal Medicine Allergy/Immunology program only.

 

 

 

PERSONAL DATA

 


Name ___________________________________________________________________

               Last                                          First                                          Middle             

 

 


Present Address ________________________________________________________________________________ 

                                                Number                                                         Street         

 

______________________________________________________________________________________________                      

           City                                              State                                             Zip       

 

Telephone No. (work) ______________________   (home) _______________________

                                                                                                                                       

                       

                        (cell)  _______________________   (fax) _________________________

                               

(e-mail) __________________________

      

Birth date _________/_________/__________

 

 

Person through whom you can always be contacted:

 

  ____________________________________

 

Relationship ____________________________

 

Address ___________________________________________________________________________________________

                                  Number                                                                 Street          

__________________________________________________________________________________________________

                      City                                   State                                                        Zip

 

 

Telephone No. (work) __________________   (home) ___________________   (cell) ___________________                                                                                      

                                       

                         (fax)  _____________________    (e-mail) _____________________

 

 

USMLE or equivalent:  Step I _______________________   Step II _______________________   Step II______________________   
                                                        (score/date taken)                                (score/date taken)                                   (score/date taken)

                                                                                                                                                           

 COMPLEX ______________________                                  ECFMG ____________________                

                             (score/date)                                                                          score/date)

 

 

Residency Specialty:         Pediatrics            Internal Medicine               Pediatrics/Internal Medicine (combined)    

 

Have you taken your specialty board exams?                  Yes       No 

 

If yes, did you pass?                                                    Yes        No  

 

                   If yes, what was your score? _______________

 

                   If not, when will you take the Boards? _________________

                                                                                       (Date)

 

                                                                                               

 

 

INTEREST AREA

 

Interested in academic medicine?  Yes _________No ________  Scale * _________________ 

 

Interested in private practice

with an academic affiliation?        Yes _________  No ________  Scale * _________________

 

Interested in private practice?        Yes _________ No ________  Scale * _________________

 

* On a scale of 1-10, please rate your interest in private medicine and academic medicine ( 1 = lowest, 10 = highest)

 

If funds are available and you are qualified by the faculty, are you interested in staying for a 3rd year or longer to do post-graduate research work?

 

Yes ___________             No ___________   Scale * ____________________

 

* On a scale of 1-10, please rate your interest in staying for a 3rd year or longer to do post-graduate research work ( 1 = lowest, 10 = highest)

 

 

Do you have special ties to Florida?  If so, please explain: 

 

_______________________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________        

 

_______________________________________________________________________________________________________________

 

 

PLEASE ANSWER THE FOLLOWING QUESTIONS: No more than 250 words for each answer.  Attach extra sheets as necessary.  Please, no exceptions.

 

 

1.        Describe the most interesting patient you have seen with an allergic and/or immunologic disease OR who has been the most influential person in your medical career and why?

 

 

 

 

 

 

 

 

 

 

 2.  Describe your research interests:

 

 

 

 

 

 

 

 

  

      3.  What are your career goals upon completion of your fellowship?

 

 

 

 

 

 

 

 

 

 

 

4.     What are your extra-curricular interests and/or hobbies?

                       

 

 

 

 

 

 

  

I certify that the information provided for this application is accurate and complete and to the best of my knowledge and understand that false information will be sufficient grounds for refusal of admission or for dismissal.  If admitted to the University of South Florida College of Medicine Post Graduate Training Program, I hereby agree to abide by the policies of the Board of Regents and the rules and regulations of the University of South Florida College of Medicine.

 

 

 

Signed _____________________________________________________  Date __________________________

 

 

WE WILL ACKNOWLEDGE RECEIPT OF YOUR APPLICATION BY E-MAIL WITHIN 2 WEEKS OF RECEIPT AND CONTACT YOU FOR ADDITIONAL INFORMATION.  IF YOU ARE NOT CONTACTED BY US WITHIN 2 WEEKS AFTER SUBMITTING YOUR APPLICATION, PLEASE CONTACT US.