UMN-SIU Leo Fung Memorial International Pediatric Fellowship

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Family Name *

First Name(s) *

Title *

Date of Birth (YYYY-MM-DD) *

Photo *

Nationality *

Native Language *

Mailing Address *

Telephone (Country Code, Area Code & Number): *

E-mail Address *

English Proficiency * ExcellentGoodModerateFair

Other Languages Spoken *

Marital Status * SingleMarriedDivorcedWidow/Widower

Number of Children *

Profession and current employment of your partner *

Hobbies (sports, culture) *

What are your future expectations and plans after the fellowship? Will you stay in academics; will you return to the Institution you are currently working in? *

How did you hear about this Fellowship (who told you) *

Membership in medical associations and societies. Positions held (if any) *

Details of Institution applying to

Time Period *

Currently employed at *

Status and Function *

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Envisioned source of funding

Do you have other funds (or scholarships) available? If so give details

Expected total expenses during scholarship

Is your family joining you?

If not, who is going to support them at home?

School Attended *

Diploma Obtained *

Year *

University Attended *

Degree Obtained *

Year *

M.D.

Ph.D.

Training since graduation (List all previous employers to date) *

Describe the Institution you are currently working in

Institution you are currently working in *

Program Director *

Number of Faculty Members *

Number of Residents *

Main areas of interest – clinically & experimentally *

Number of urological surgical procedures performed per year in your department

TURP *

TURB *

Nephrectomy *

Cystectomy *

Urinary Diversion (list specific procedures) *

Radical Prostatectomy *

Ureteroscopy *

Pediatric urology procedures (hypospadias, antireflux etc.) *

Special procedures *

Describe special areas of clinical expertise in your hospital (e.g. bilharzia, tuberculosis, ureteral disease, trauma, vesico-vaginal fistulae, extensive stone disease …) *

Clinical

Experimental

Ultrasound

Percutaneous Nephrostomy

Urodynamics

Andrology

Pediatric Urology

Oncology

Endoscopy

List the number of following procedures performed by yourself to date

Major procedures (cystectomy, radical prostatectomy, urinary diversion) *

Large procedures (e.g. nephrectomy) *

TUR Prostate *

TUR Bladder *

Endoscopy *

Minor cases (e.g. hydroceles, circumcisions) *

Pediatric cases (antireflux proc., hypospadias) *

Special Procedures *

Your publication list (most recent first) *

Personal Statement: Describe your qualifications and reasons for seeking this fellowship. *

Detailed CV

Please upload professional references
(formats accepted: Word, PDF, JPG) *

Please upload a recommendation letter from the immediate supervisor at the home institution
(formats accepted: Word, PDF, JPG) *