Academic General Pediatrics Fellowship Programs Common Application for the 2025 Pediatric Specialties Match via NRMP2025 Medicine and Pediatric Specialties Match . Registration opens on August 28, 2024 at 12PM EST.
First Name:
* must provide value
Last Name:
* must provide value
Contact Email:
* must provide value
Phone Number:
* must provide value
Emergency Contact - Name and Number:
* must provide value
City:
* must provide value
State/Province:
* must provide value
Zip/Postal Code:
* must provide value
Citizenship
* must provide value
US Citizen US Permanent Resident Other
Will you need a "Visa sponsorship" through the teaching hospital (J1, H1b, Etc.) to participate in US Fellowship training?
Yes
No
If yes to above: Please specify type of Visa:
Did you train at a foreign medical school?
Yes
No
Is your medical school listed on the approved list for state licenses to which you will be applying?
Yes
No
Unsure - if unsure, please contact the programs to which you are applying. Obtaining state license, for the state in which you will be training, is mandatory to fellowship
ECFMG/TOEFL Scores:
College/University:City, State: Dates: Degree Program:
* must provide value
Degree:
* must provide value
Yes
No
Medical School:City, State: Degree Program:
Yes
No
Internship:City, State: Dates:
Yes
No
Residency:City, State: Dates:
Yes
No
Other Training:City, State: Dates:
Degree/Certification:
Was your medical education/training extended or interrupted?
* must provide value
Yes
No
If yes, please note the date and comment:
* must provide value
Have you passed the USMLE Step 3?
* must provide value
Yes
No
No current medical license (If you do not have a current medial license, skip to the "Board Certification" questions).
* must provide value
Yes
No
State:
State:
DEA Registration Number:
DEA Expiration Month/Year:
(DEA is for US Medical License holders only)
Has your medical license ever been suspended, revoked, or voluntarily terminated?
* must provide value
Yes
No
If yes, please note the date and comment:
Have you ever been named in a malpractice case?
* must provide value
Yes
No
If yes, please note the date and comment:
Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?
* must provide value
Yes
No
If yes, please note the date and comment:
Are you Board Certified?
* must provide value
Yes
No
If NO, will you be Board Eligible by the beginning of the fellowship?
* must provide value
Yes
No
Are you Board Certified/Eligible for more than one Board?
* must provide value
Yes
No
If YES, will you be Board Eligible by the beginning of the fellowship?
* must provide value
Yes
No
Are you able to carry out the responsibilities of a fellow in Academic General Pediatrics and at
* must provide value
Yes
No
Reference 1Name and Title: Contact Information: Address: Email: Phone
* must provide value
Reference 2Name and Title: Contact Information: Address: Email: Phone
* must provide value
Reference 3Name and Title: Contact Information: Address: Email: Phone
* must provide value
Personal StatementPlease attach a one-page personal statement explaining why you want to complete a fellowship in Academic General Pediatrics and/or Primary Care. Please include the following: a description of your career goals, how the fellowship may assist you in achieving them, your scholarly/research interest, and how you envision your career five years after completion of the fellowship. You may want to include how past experience have influenced your decision to apply and mention special areas of interest (Please include your name on the attachment).
* must provide value
AttestationI certify that the information contained in the application is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me from consideration for a position, or if employed, may constitute cause for termination from the program. I also understand and agree that the data included in the application may be shared within the fellowship programs to which I am applying.
* must provide value
I agree with the above attestation
Ethnicity (Self-identification)
Of Hispanic or Latino Origin (a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish Culture or origin regardless of race)
Not of Hispanic or Latino Origin
Race (Self-identification)
Black or African American: A person having origins in any of the original groups of Africa.
Asian or Asian-American: Includes persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian sub-continent (e.g. Cambodia, China, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam).
American Indian or Alaskan native: Includes persons having origins in any of the original peoples of North America and South American (including Central America), who mains tribal affiliation or community attachment.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.
White: Includes persons having origins in any of the original peoples of Europe, North Africa or the Middle East.
Disadvantaged Background:An individual from a disadvantaged background is defined as someone who: Comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession. OR Comes from a family with an annual income below a level based on low-income thresholds according to family size published by the US Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of Health and Human Services for use in health professions and nursing programs.
Yes
No
Checklist for Submission
Register for the Pediatric Fellowship Fall Specialties NRMP Match using the followling link: https://r3.nrmp.org/viewLoginPage Contact EVERY program you plan to apply to in order to: Introduce yourself Verify the deadline for application submission Determine if there are any other program specific documents that need to be submitted to be consider for the fellowship Ask any additional questions you may have Submit the following items via email directly to each Fellowship Program Director**: Complete APA Common Application Personal Statement - Please include your name on the attachment Updated Curriculum Vitae Instruct your three (3) letter writers to submite their letters of recommendation and a completed Confidential Reference Report via email directly to each Fellowship Program Director** **Please see Appendix I for a comprehensive list of email addresses