Application for University of Washington Four Year Pathway

WE ACCEPT TYPED APPLICATIONS ONLY. HANDWRITTEN APPLICATIONS WILL NOT BE ACCEPTED.

INSTRUCTIONS
The completed form should be returned to Trixie Rombouts ([email protected])

Date Date you wish to begin training

Full name
Date of birth
Citizenship
Business address Phone
Home address Phone

PREMEDICAL EDUCATION
College Address Date: From-To Degree

MEDICAL EDUCATION
College Address Date: From-To Degree

INTERNSHIPS, RESIDENCIES, AND FELLOWSHIPS

Position City Institution Type of service Date From-

To

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USMLE Step 1: _______/_______ Step 2 CK: _______/_______ Step 2 CS: Pass / Fail Step 3:
_______/_______
ARE YOU LICENSED TO PRACTICE MEDICINE? Where?

MILITARY SERVICE AND PRESENT STATUS

Board Eligibility

• ECFMG status or other qualifications

• Visa type Visa number Visa expiration

HONORS, SCHOLARSHIPS, GRANTS

MEMBERSHIP IN PROFESSIONAL SOCIETIES

PUBLICATIONS

SPECIAL TRAINING AND INTERESTS

• Have you had any special training or experience that could contribute to a research project
during your training? If so, please describe

YES answers to the following questions require a written explanation on a separate sheet
(positive responses to questions do not necessarily preclude acceptance).
Have you ever been involved in a malpractice lawsuit or claim (whether or not you were
Yes No
individually named as a defendant)?

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Have you ever been called before any entity for questioning concerning unprofessional conduct,
Yes No
incompetence, negligence, unsafe practices, or mental or physical impairment?
If you have been licensed to practice medicine, has any such license, or application for it, ever
Yes No
been denied, revoked, suspended, or restricted?
Have you ever been addicted to, or treated for addiction to, a controlled substance, drug, or
chemical? Yes No
Have you ever used a prescription drug, including controlled substances, for other than
therapeutic Yes No
purposes?
Are you currently suffering from any disability or illness (mental or physical) that could affect your
Yes No
ability to fully practice medicine?

On a separate sheet narrate your reasons for seeking fellowship training, your long range
objectives in radiology and the amount and type of subsequent training you desire.
• Where do you contemplate locating after your training?
__________________________________________________

REFERENCES
• List a minimum of three references. We require three letters of recommendation including a
letter from your residency training program, a letter from your current fellowship (if attending),
and a letter from other faculty, colleagues, or fellowship directors.

Name Title Address

Signature Date

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 CLINICAL EXPERIENCE QUESTIONNAIRE

Name: _________________________________________________________
CT EXPERIENCE:

1-What type of CT scanner do you have most experience with? Mark all that apply.

64 slice MDCT

256 slice or newer generation MDCT

Dual energy

Dual source

Revolution (GE) or similar

Others

None

2-On the average, how many CT exams do you read per day?

3-Do you have experience with the following types of CT examination? Mark all that apply. For each
category please state how many cases per month you are exposed to.

CT Type Number of cases per

month

CT angiography (CTA of
chest or abd or pel
including PE studies)

Multiphase CT of liver

Multiphase CT of pancreas

Routine CT Abd/Pel

CT IVP

CT chest

CTA coronary or cardiac

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4-How often do you protocol CT examinations in your practice?

Comments:

CLINICAL EXPERIENCE QUESTIONNAIRE

Name: _________________________________________________________
MRI EXPERIENCE:

1-What type of MR scanner do you have most experience with? Mark all that apply.

0.5T

1.5 T

3T

None

2-On the average, how many MRI examination of the body (excluding MSK exams) do you read per month?

3-Do you have experience with the following types of MRI examination? Mark all that apply. For each category
state how many cases per month you are exposed to.

MRI type Number of cases per month

Liver

kidneys

Pancreas

Female GU

Male GU

Fetal

MR angiography (MRA)

MRI Cardiac

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4-How often do you protocol MRI examinations?

Comments:

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 CLINICAL EXPERIENCE QUESTIONNAIRE

Name: _________________________________________________________

US EXPERIENCE:

1-What type of US exams do you have experience with? Mark all that apply. For each category please state the
average number of cases you are exposed to per month.

US exam type Number of cases per month

Abdominal US

Renal/retroperitoneal

Gynecological US

First trimester OB

Second trimester OB

High risk OB

Renal Transplant

Liver Transplant

Pancreas Transplant

2-How often do you scan the patient yourself?

Never

Only some cases

Only if the attending wants me to

Every case

Comments:

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 CLINICAL EXPERIENCE QUESTIONNAIRE

Name: _________________________________________________________

IMAGING GUIDED INTERVENTIONAL PROCEDURES:

1-What type of US guided invasive procedures do you have experience with? Mark all that apply. For each
category please provide the best approximation of the number of procedures you have performed.

Number of cases

Thoracentesis

Paracentesis

Other Aspiration

Thyroid FNA

Liver biopsy

Superficial biopsy

2-What type of CT guided invasive procedures do you have experience with? Mark all that apply. For each
category please provide the best approximation of the number of procedures you have performed.

Number of cases

Lung biopsy

Solid Organ biopsy

Lymph node biopsy

Peripheral mass biopsy

Comments:

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