MWH FM OB Fellowship application

MWH FM OB Fellowship application

We are excited that you have chosen to further your training in Family Medicine Obstetrics and look forward to reviewing your application to our fellowship program. Applications are accepted from January 1st through July 31st for the fellowship year starting in July of the following year.

Name*

Street Address

Address Line 2

City

State/Province Region

Zip/Postal Code

Phone*

Phone

Email*

Documents

Please upload the following:

Three letters of recommendation, including one from your current program director
Personal statement describing your interest in the program and future career goals with your professional photograph
Medical school diploma and transcripts
Procedure log from residency (including vaginal deliveries, c-sections, other obstetric procedures, ultrasound, and all non-OB inpatient and outpatient procedures i.e. gynecology, circumcisions, dermatology)
Board Certification in Family Medicine by Fellowship start date
Boards and In-Training Exam scores (you may send your own score transcript/ an official copy is not required)
Current Medical License
Virginia DEA (required by start date of fellowship)
Please label files according to BOLD items above

Upload documents*

Drag and drop files here or

Do you have any condition(s) which might interfere with your ability to complete the requirements of the fellowship? If yes, please provide an explanation.*

Yes

Have you had or are you currently on probation (academic, medical or otherwise) at your home institution? If yes, please provide an explanation.

Yes

Has your medical license been suspended or revoked for any reason? If yes, please provide an explanation.*

Yes

Are you a U.S. citizen? If not, please explain your status. (We are currently unable to sponsor visas at this time.)

Yes

USMLE/COMLEX

USMLE Level 1 or COMLEX Step 1 Result(s)*

Pass

Fail

Other

Score #

USMLE/COMLEX Step 2 Score*

USMLE/COMLEX Step 3 Score

In Training Exam Score(s)

First Year ITE Score*

Second Year ITE Score*

Third YEar ITE Score

List OB/GYN rotations (include anticipated rotations if still in residency training)

Please specify number of weeks in Labor and Delivery and Obstetrics and Gynecology in the Outpatient Clinic.

Required Rotations*

How many weeks in Labor and Delivery?

How many weeks in the OB/GYN outpatient clinic?

Elective Rotations*

Learning Opportunities outside of residency curriculum "(i.e. volunteer experiences, etc.)"

List CME Conferences attended

What are your goals for fellowship training in obstetrics?*

What are your future practice plans and how you do you see obstetric fellowship training enhancing your future practice?*

Send me a copy of my responses

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