ACS National Surgical Quality Improvement Program

Application for Funded Outcomes & Health Services Researcher Northwestern University – Surgical Outcomes and Quality Improvement Center (SOQIC)

Fellowship period: July 1, 2017 - June 30, 2019

Instructions: Please complete this document in Microsoft Word and e-mail as an attachment to remi- [email protected] along with a curriculum vitae and research proposal/statement as described below. PLEASE INCLUDE ALL DOCUMENTS IN ONE E-MAIL.  Recommendation letters should be e-mailed directly from the letter writers to [email protected]  Applicants will be notified once their file is complete.  Please e-mail us with any questions: [email protected]

Application Checklist

PLEASE INCLUDE ALL COMPONENTS IN ONE EMAIL. THE APPLICATION, SUPPORTING DOCUMENTS, AND LETTERS OF RECOMMENDATION MUST BE RECEIVED BY THE DUE DATE.

1. Application form 2. Curriculum vitae or resume 3. Research Plan/Personal Statement 4. Any additional supporting documentation

Contact Information

Last Name Date of Birth

First Name Age

Address E-mail

City/State/ZIP Code Pager

Phone Fax Current PGY Level Residency Information

Institution 1 Institution 2

Dates Attended Dates Attended

Address Address

City/State/ZIP Code City/State/ZIP Code

Phone Fax Phone Fax

Education

Medical School College

Dates Attended Degrees Earned Dates Attended Degrees Earned

Address Address

Phone Fax Phone Fax

Other Graduate School Other Graduate School

Dates Attended Degrees Earned Dates Attended Degrees Earned

Address Address

Phone Fax Phone Fax

Surgical Outcomes and Quality Improvement Center (SOQIC) Research Fellowship ApplicationPage 2 of 4 Research Plan/Personal Statement- 1500 Word Limit

In a separate Microsoft Word document, please describe your research interests, your career aspirations, and how the SOQIC research fellowship will help you achieve your goals. Include your prior research experience, any advanced research degrees, and any relevant statistical, epidemiologic, or programming experience. A specific research project does not need to be outlined here, but please note if you have specific research interests. Please include the Research Plan/Personal Statement in the application e-mail as an attachment and email to remi- [email protected] .

Curriculum Vitae

In a separate document, please include your curriculum vitae or résumé. E-mail as an attachment to [email protected]

Please be sure to include 1. Publications (full citations) 3. Awards / Honors 2. Presentations (specify oral or poster; full citations) 4. Previous grants / research funding

Miscellaneous Yes No

1. Are you a US Citizen?

If not, are you authorized to work in the United States? (Please explain in a separate statement)

2. Have you ever been convicted of a felony? If yes, please attach letter explaining the circumstances

3. Have you ever had a medical license revoked or suspended? If yes, please attach letter explaining the circumstances

Surgical Outcomes and Quality Improvement Center (SOQIC) Research Fellowship ApplicationPage 3 of 4 Letters of Recommendation

Please provide two letters of recommendation. Letter writers should e-mail the letters to remi- [email protected].

Letter 1: Surgery Department Chairman: This letter should comment on applicant’s character, potential, abilities, and career plan. In addition, the Chairman must guarantee to the Selection Committee that the resident will be able to suspend his or her residency for two years to participate in the SOQIC fellowship.

Letter 1: Contact Information for Chairman

Last Name Degree and Title

First Name Institution

Address E-mail

City/State/ZIP Code Phone

Letter 2: Previous Research Mentor, Program Director, or Other Faculty Surgeon. This letter should comment on the applicant’s character, abilities, potential, and career plan.

Letter 2: Contact Information for Other Reference

Last Name Degree and Title

First Name Institution

Address E-mail

City/State/ZIP Code Phone

Surgical Outcomes and Quality Improvement Center (SOQIC) Research Fellowship ApplicationPage 4 of 4