DFCI Post Graduate PA Oncology Fellowship

DFCI Post Graduate PA Oncology Fellowship

Personal Information

Legal Name*

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Preferred First Name

Preferred Pronouns

Current Mailing Address*

Personal Email Address*

Primary Phone Number*

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Education Information

Undergraduate/Baccalaureate University

School Name*

City and State of School*

Matriculation Date*

Date of Graduation*

Major or Concentration*

Degree Earned*

Master’s/Post-Baccalaureate/Physician Assistant Program

School Name*

City and State of School*

Matriculation Date*

Graduation Date (Masters)*

Degree Earned*

Do you have any other advance degrees?*

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If yes, please specify*

Work Experience 1

Please list your most to least recent work experience

Job Title*

Employer*

Date Started*

Date Ended*

Brief Summary of Responsibilities*

Name of Manager*

Can we contact this manager?*

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Manager Contact Number*

Phone

Other Work Experience?*

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Work Experience 2

Job Title*

Employer*

Date Started*

Date Ended*

Brief Description of Responsibilities*

Name of Manager*

Can we contact this manager?*

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Manager Contact Number*

Phone

Other Work Experience?*

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Work Experience 3

Job Title*

Employer*

Date Started*

Date Ended*

Brief Description of Responsibilities*

Name of Manager*

Can we contact this manager?*

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Manager Contact Number*

Phone

References

Please fill out this section to correlate with the references who write letters of recommendation. Please attach three letters of recommendation with the application.

Reference #1: must be from either the Clinical or Medical Director of applicant’s PA graduate program and dated no more than six months prior to the application date. This letter must reflect current standing in the PA program and list completed rotations.

Reference #2: must be from a clinical preceptor who has worked with the applicant closely during their clinical rotation year. There is no specific rotation requirement, but Internal Medicine, Ambulatory Medicine, Emergency Medicine, or Oncology elective rotations are encouraged. For practicing PAs we ask for a manager who can comment on your clinical ability to write a reference letter in place of a preceptor.

Reference #3: must be a character reference from any clinical preceptor or previous employer who knows the applicant well and can comment on clinical performance and bedside manner.

Reference 1

Full Name*

Email Address*

Direct Phone Number*

Phone

Relationship to applicant*

Any other details

Do you have any other references?*

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Reference 2

Full Name*

Email Address*

Direct Phone Number*

Phone

Relationship to applicant*

Any other details*

Do you have any other references*

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Reference 3

Full Name*

Email Address*

Direct Phone Number*

Phone

Relationship to applicant*

Any other details

Statements

No more than one page in length for each essay, standard font and spacing. Please attach these documents with the application

Statement #1: Please explain your interest in the Dana-Farber postgraduate PA Oncology fellowship and in Oncology as a whole.

Statement #2: What do you view as an important issue facing society and medicine today, and what is your personal relationship or perspective on this issue?

Attachments below:*

Please attach a Curriculum Vitae or Professional Resume with this application. Additionally, please upload 2 essay statements, 3 letters of recommendation and government issued ID.

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Signature

By entering my name and the date below, I attest that the above information is my own work, factually accurate, and genuinely presented. I hereby authorize all schools I

previously attended or am now attending to release to Dana-Farber Cancer Institute, Inc. (“DFCI”) all requested educational records, including academic records, student

development/conduct, and financial assistance, for the purpose of evaluating my application to the Dana-Farber Cancer Institute Physician Assistant Fellowship Program

and I intend that my authorization herein meets the requirements of applicable law, including, if applicable, the Family Educational Rights and Privacy Act (“FERPA”) (20

USC Section 1232g; 34 CFR Section 99.30 et seq.) and 603 CMR 23.07(4). Further, I authorize DFCI to contact the references I have listed herein and to discuss, orally or in writing, my past or current employment, work or volunteer history with these references. I hereby agree to release and discharge DFCI, its employees, officers, directors and agents from all claims related to these oral or written discussions with my references. Should the information I have presented herein be misleading or false, I understand that I may be subject to a range of possible disciplinary actions, including admission

revocation or expulsion from the Dana-Farber Cancer Institute Physician Assistant Fellowship Program

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Date*

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