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Application For Surgeons: Clinical Research Fellowship: (Only Typewriting Accepted)

This document is an application for a clinical research fellowship at the AO Innovation Translation Center (AO ITC). It requests personal and professional information from applicants, including details of their medical education and training, research experience, publications, language skills, and availability for a fellowship in 2022. Applicants are asked to provide references and documents like a CV, publications list, medical diploma, AO Principles Course certificate, and letters of recommendation. The deadline for submission is also specified.

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Dr Payal Luthra
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35 views4 pages

Application For Surgeons: Clinical Research Fellowship: (Only Typewriting Accepted)

This document is an application for a clinical research fellowship at the AO Innovation Translation Center (AO ITC). It requests personal and professional information from applicants, including details of their medical education and training, research experience, publications, language skills, and availability for a fellowship in 2022. Applicants are asked to provide references and documents like a CV, publications list, medical diploma, AO Principles Course certificate, and letters of recommendation. The deadline for submission is also specified.

Uploaded by

Dr Payal Luthra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Application for Surgeons: Clinical Research Fellowship

(Only typewriting accepted)

Personal information

Last name:

First name:

Current photo Date of birth:

Nationality:

Marital status:

Full home address:

Home phone:

Email address:

Name of university/hospital:

Full address of hospital: (If you are in private practice, please explain your position and indicate name and address of the hospital.)

Work phone:

Work fax:

Present position:

Name of head of clinic:

Name of head of department:

Languages spoken: ☐ English ☐ French ☐ German ☐ Spanish ☐ Others:

Form 04.013/01 06.07.2021 Page 1 of 4


Medical school

Name of school:

Full address:

Date of start (mm.yyyy): Date of graduation (mm.yyyy):

Post-graduate education - orthopedic trauma surgery

Where:

Duration:

Qualification:

Details about special training in clinical research (EBM-Epidemiology)

Where:

Duration:

Qualification:

Have you completed a previous AO fellowship in an AO clinic? ☐ Yes ☐ No

Where: When:

Are you active in research? ☐ Yes ☐ No

Clinical and/or experimental? Please explain:

Have you written any publications? ☐ Yes ☐ No


(Please attach your bibliography)

What do you expect from your stay with AO ITC ?

Form 04.013/01 06.07.2021 Page 2 of 4


To which clinical division are you affiliated?
☐ AO Trauma Membership number:
☐ AO CMF ☐ AO Spine

Have you attended an AO Principles Course? ☐ Yes ☐ No

If yes, where and in which year? (Please enclose a copy of your certificate)

If no, when do you plan to attend one?

Please note: AO fellowships are only granted to candidates who have completed an official AO Principles Course
(workshops, seminars, etc. are not acceptable)

What are your future professional goals?


(Please answer as precisely as possible)

Do you plan to continue your career at the same clinic? ☐ Yes ☐ No

If no, do you have another definite appointment? ☐ Yes ☐ No

Where:

Position:

Date of start:

Please indicate the most convenient date(s). Note that the fellowship will take place next year (2022)
(Be aware that the months of July and August are generally not recommended due to summer holidays.)

If you are granted an AO ITC fellowship, are you planning to come alone? ☐ Yes ☐ No

Are you considering attending a special course in clinical epidemiology?


☐ No
☐ Yes (Please give details inclusive dates)

Which AO members do you personally know? (Please explain your association with them)

Form 04.013/01 06.07.2021 Page 3 of 4


Other references:

Remarks:

Signature: Place and date:

Please enclose the following documents with your application:

1. Curriculum vitae
2. List of publications and major lectures given by the applicant
3. Copy of medical school diploma
4. Copy of AO Principles Course Certificate
5. 2 letters of recommendation
6. 1 recent passport size photograph
7. Fellowship Project Outline
8. Copy of ethical approval from competent authorities (only for fellows bringing their own database for analysis).
Include a translation to English.

Please submit this form and the above documents to:

Electronic format (preferred): [email protected]


or
Paper copies (only if electronic format is not possible): AO Innovation Translation Center
Clinical research fellowship program
Stettbachstrasse 6
8600 Dübendorf, Switzerland

Form 04.013/01 06.07.2021 Page 4 of 4

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