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APPLICATION TO THE MEDICAL PHYSICS RESIDENCY PROGRAM AT DUKE UNIVERSITY MEDICAL CENTER

PLEASE NOTE: YOUR COMPLETED APPLICATION MUST INCLUDE THE FOLLOWING COMPONENTS:

(A) PERSONAL INFORMATION FORM (B) CURRICULUM VITAE (C) REFERENCES FORM (D) A PERSONAL STATEMENT REGARDING FUTURE GOALS. (E) THREE LETTERS OF RECOMMENDATION (CORRESPONDING TO ITEM (C)). (F) TRANSCRIPT FROM COURSE OF STUDY (IF IN ANOTHER LANGUAGE, SHOULD BE ACCOMPANIED WITH A CERTIFIED ENGLISH TRANSLATION)

ITEMS A–C AND E ARE TO BE COMPLETED AS DETAILED ON THE FOLLOWING PAGES.

ITEMS A-F SHOULD BE EMAILED (SEE BELOW) AT THE EARLIEST POSSIBLE TIME. A SCANNED COPY OF ITEM F MUST BE EMAILED, BUT ALSO FOLLOWED BY A CONFIDENTIALLY SEALED HARDCOPY.

Email items A-F to: [email protected]

Mail item F to: Carolyn F. Crank Department of Radiation Oncology Box 3295, Duke University Medical Center Hospital South Red Zone Morris Building, Durham, NC 27710 2

(A) PERSONAL INFORMATION FORM

Date Submitted: Full Name : (include highest degree) Current Mailing Address:

(City, State Zip Code): Permanent Mailing Address:

(City, State Zip Code): Day-time Telephone Number: - - Evening Telephone Number: - - Fax number: - - e-mail Address: Current Position: Position Title: Beginning Date: Department: Organization: Location: Personal Information: Gender: Citizen of: U.S. Visa Status (if applicable):

Date Education: Institution & Location (year) Degree Major College

Graduate or Professiona l School 3

(A) PERSONAL INFORMATION FORM (CONTINUED)

(a) Do you have a physics major? ___ Yes ____No If you answered No to the above question: (b) Do you have a physics minor with major in natural science, mathematics, or engineering? ___ Yes ____No If you answered Yes to question (b), please enter details in the table below. If you do not have courses in the required categories, leave blank.

Course name: ______Course number: ______, Year taken: ______

2 semesters of general physics Course name: ______Course number: ______, Year taken: ______

1 semester of modern Course name: ______physics Course number: ______, Year taken: ______

Course name: ______Course number: ______, Year taken: ______

2 semesters of calculus Course name: ______Course number: ______, Year taken: ______

1 semester of computer Course name: ______science/programming Course number: ______, Year taken: ______

1 semester of Course name: ______chemistry Course number: ______, Year taken: ______

Course name: ______1 semester of biology Course number: ______, Year taken: ______

1 semester of Course name: ______electronics Course number: ______, Year taken: ______4

(A) PERSONAL INFORMATION FORM (CONTINUED) The following are courses that you will need to have completed by the end of residency (unless you have already taken an equivalent course). Please indicate below the equivalent course name, number and grade, where applicable. Note that auditing will not be considered as equivalent to having taken the course for grade. If you are selected for residency, you will be required to complete courses (not already taken) in the Duke Medical Physics Graduate Program.

1. Radiobiolgy. A course covering the basics of Radiobiology.

Course name and number:______Grade received ______

Name of School______

2. Radiation physics. A course covering the basics of ionizing and non-ionizing radiation, atomic and nuclear structure, basic nuclear and atomic physics, radioactive decay, interaction of radiation with matter, and radiation detection and dosimetry.

Course name and number:______Grade received ______

Name of School______

3. Radiation therapy physics. This introductory course has a clinical orientation, and reviews the rationale, basic science, methods, instrumentation techniques and applications of radiation therapy to the treatment of a wide range of human diseases. Major radiation modalities are covered including low and high energy photon therapy, electron and proton therapy, and low and high-dose rate brachytherapy. The clinical process of treatment, methods of calculating dose to patient, and the role of the medical physicist in radiation oncology clinic, are covered in detail.

Course name and number:______Grade received ______

Name of School______

4. Anatomy and physiology for medical physicists. A course focused on medical terminology, biochemistry pertaining to MP, basic Anatomy and physiology, elementary tumor and cancer biology, and overview of disease in general. Upon completion, the student should: (a) understand anatomic structures, their relationships, their cross-sectional and planar projections, and how they are modified by attenuation and artifacts in the final images; (b) understand the physiology underlying radionuclide images, (c) understand how (a) – (b) are modified by disease, (d) identify anatomical entities in medical images (different modalities), and (e).identify basic 5 disease features in medical images (e.g., Pneumothorax in chest radiographs, microcalcoifications in mammograms).

Course name and number:______Grade received ______

Name of School______

5. Advanced photon beam radiation therapy. This course will cover thephysics and clinical application of advanced external beam photon therapies with special emphasis on IMRT, dose calculation algorithms and image fusion.

Course name and number:______Grade received ______

Name of School______

6. Radiation protection. Course discusses the principles of radiation protection dealing with major forms of ionizing and non-ionizing radiation, the physics and chemistry of radiation biology, biological effects of ionizing and non-ionizing radiations (lasers, etc.) at cellular and tissue levels, radiation protection quantities and units, medical HP issues in clinical environments, radiation safety regulations, and basic problem solving in radiation safety.

Course name and number:______Grade received ______

Name of School______

7. Medical imaging physics. A course describing basics of imaging science, xray imaging modalities including basic principles, detectors, scattered radiation, planar imaging, CT, fluoroscopic imaging, nuclear medicine imaging, US and MRI, and computers in imaging.

Course name and number:______Grade received ______

Name of School______6

(B) CURRICULUM VITAE FORMAT

Your Curriculum Vitae should provide the following information:

1. Full name, with highest completed degree 2. Education, including the name and location of all undergraduate and post-graduate schools attended, years of attendance, degrees earned, and major concentration area 3. Scholarly honors and awards, professional awards and recognition 4. Specialty licenses and board certifications, if any 5. Postgraduate job experience, professional training, and academic career. List chronologically, beginning with first post-graduate position. Include research fellowships, teaching assistantships and responsibilities, and clinical activities. For each entry, list years of participation, your position title, and the organization and location. 6. Publications including refereed publications, book chapters, and selected abstracts. Use boldface type to highlight your name among the list of co-authors. 7. Membership in professional organizations. Indicate offices held or participation on committees, if any. 8. Participation in academic and administrative activities at a university or medical center 9. Grant participation, past and present. Provide following grant information: Principal Investigator’s name, title or brief description of grant, and description of your participation. 10. U.S. Patents held

Your name and the page number must appear on each page of your CV. 7

(C) REFERENCES FORM

Name of Applicant: Date: List of References Provide complete contact information for three persons who are qualified to comment on your competency in a research, academic, and/or patient care setting. References should be able to answer questions about you, if contacted in person.

Reference 1 Name: Position: Organization: Address: Telephone Number: E-mail Address:

Reference 2 Name: Position: Organization: Address: Telephone Number: E-mail Address:

Reference 3 Name: Position: Organization: Address: Telephone Number: E-mail Address: 8

(E) LETTERS OF RECOMMENDATION Each letter of recommendation must follow the format below. Cut the section below and email to your references. They must complete the sections and email to us (emails should come directly from the references, not from the applicant).

Please indicate your selection with “X” in the table below Category Superior Good Fair Poor Unable to judge Medical Physics knowledge Problem solving capability Degree of responsibility Ability to take initiative in pursuing work goals Communication skills - verbal Communication skills - written Ability to work with others Ability to work in clinical environment

Describe, in detail, your interactions with the candidate – coursework, projects, personal impressions, etc.

On a scale of 1 – 10 (1 = do not recommend, 10 = highly recommend), how would you rate this individual: ______