<p> APPLICATION FORM:</p><p>APPLICATION FOR TRAINING CENTRES EDUCATION AND TRAINING FELLOWSHIP PROGRAMME FOR INTERVENTIONAL CARDIOLOGY</p><p>THE EUROPEAN ASSOCIATION OF PERCUTANEOUS CARDIOVASCULAR INTERVENTIONS A Registered Branch of the ESC</p><p>EDUCATION AND TRAINING FELLOWSHIP PROGRAMME</p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected] APPLICATION FOR THE EAPCI EDUCATION AND TRAINING FELLOWSHIP PROGRAMME</p><p>Thanks to the financial support from industries sponsors, the European ASSOCIATION OF CARDIOVASCULAR INTERVENTIONS (EAPCI), a registered branch of the European Society of Cardiology (ESC), is offering an Education and Training Fellowship Programme available to qualified Medical Doctors and Cardiologists working in the field of Interventional Cardiology. We invite separate applications from both individuals and centres to be matched exclusively by the EAPCI Fellowship Committee. The starting period for applications is 14th October 2016.</p><p>The deadline for applications is 15 January 2017, with a start date between 1 June and 31 December 2017.</p><p>Prior to completing this form, please carefully read the Rules and Regulations for the EAPCI Education and Training Fellowship Programme for interventional cardiology.</p><p>Rules are available on the EAPCI website: http://www.escardio.org/Education/Career-Development/Grants-and-fellowships/EAPCI-interventional- cardiology-training-and-research-grants</p><p>All parts of the application form must be returned by 15th January 2017</p><p>Any application received by fax and/or post only or received after the mentioned deadline will not be acceptable.</p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected] APPLICATION FOR THE EAPCI INTERVENTIONAL CARDIOLOGY EDUCATION AND TRAINING GRANT</p><p>Name Centre</p><p>City Country Phone number* Fax Number* e-mail *: These fields are not mandatory</p><p>Address of Centre</p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected] HEAD OF THE DEPARTMENT APPLYING FOR THE EAPCI EDUCATION AND TRAINING FELLOWSHIP PROGRAMME </p><p>1. Name and title: </p><p>2. Name and address of Department: </p><p>Phone number * Fax number * Email *These fields are not mandatory </p><p>3. Name and position of proposed Fellowship Supervisor: </p><p>Phone number * Fax number * Email *These fields are not mandatory </p><p>4. Name and title of Administrator for the Fellowship Programme: </p><p>Phone number * Fax number * Email *These fields are not mandatory </p><p>5. Please state in a few words:</p><p> a. Why the centre is appropriate for this training and how it will ensure that candidates meet their objectives :</p><p> b. How many fellows and from which countries, did you train for at least 6 months, over the last 5 years?</p><p>1 year Training fellows Total fellows</p><p>Past (last 5 years)</p><p>Present</p><p>Expected during the grant period</p><p>6. Could you please give a starting date (between 1 June and 31 December 2017) to welcome the fellow?</p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected] a. Could you specify if their activities were orientated more on Basic Science, Clinical research or both? b. Could you specify which of the metallic and/or bioabsorbable drug-eluting coronary stents are used in your lab? c. Other?</p><p>7. Could you specify which of the transcatheter aortic valve system is used in your lab? a. Other? b. We do not perform aortic valve interventions.</p><p>8. Could you specify which of the TRANSCATHETER MITRAL VALVE SYSTEM is used in your lab? a. Other? b. We do not perform mitral valve interventions.</p><p>9. Could you specify which of the following structural heart disease interventions is performed in your lab? Please specify devices: a) laa closure yes no devices: b) pfo closure yes no devices: c) asd closure yes no devices: d) vsd closure yes no devices: e) paravalvular leak closure yes no devices: f) we do not perform structural heart interventions</p><p>10. Could you specify which of the intracoronary imaging system (IVUS/OCT/NIRS) is used in your lab? a) b) c) d) e) Other?</p><p>11. Could you specify which of the physiological lesion assessment system is used in your lab? a) b) c) Other?</p><p>Fluoroscopy / angiographic system: Siemens  Phillips  GE  Other: ______</p><p>Do you have a hybrid room? yes no do you have cardiac surgery on-site? yes no</p><p>12. Short description of the training you provide to training fellows?</p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected] 13. How many fully recognised interventional cardiologists are working in your centre?</p><p> a) Number of PCI per year: b) Number of TAVI per year: c) Number of mitral valve interventions per year: d) Number of structural heart disease interventions per year: e) Number of IVUS per year: f) Number of OCT per year: g) Number of FFR per year:</p><p>14. Could you please indicate if you have a fellow to suggest?</p><p>15. Can you certify that all the educational activities will be delivered in English? yes / no </p><p>16. Do you have restrictions to welcome foreigners? </p><p>17. What are the requirements in your country and/or your centre? </p><p> Working permit? yes / no</p><p>Details: </p><p> To be compliant with the EU regulation 36-2005, does the applicant need to speak the native language of your country? </p><p> yes / no</p><p>If yes: Required level: Basic / Fluent</p><p>Is this level required upon his/her arrival already? yes / no</p><p>Does the applicant needs to provide a certificate on the native language of the country to be able work on patient?</p><p> yes / no</p><p>If no: please indicate which language(s) the applicant needs to speak: </p><p> please be aware that compliance with the EU regulation 36-2005 remains the responsibility of your centre and EAPCI cannot be held responsible for any information / requirement that you have not mentioned. </p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected]  Other requirements?</p><p>18. As part of the Programme, the Department will be requested to publish documents in the Eurointervention (or in any other equivalent peer review journal) and/or to submit one abstract at the EAPCI official congress (EUROPCR). Results of the training shall be jointly owned by the ESC/Association, the host institution and the fellows. Acknowledgment of the grant will be stated in all these materials.</p><p>Please give the references of three recent papers on Interventional Cardiology published from your institution in an international peer-reviewed cardiology journal (authors, title, journal, pages): ACCEPTANCE AND CONDITIONS</p><p>I am aware that as a Training Centre in the EAPCI Education and Training Fellowship Programme, for all fellows appointed by EAPCI, there will be a contract (employment, training) between the host institution and the fellow to be countersigned by the ESC and the EAPCI.</p><p>The centre is responsible for the set up of the legal framework of the fellow in accordance with local regulations and the fellow will be subject to the terms of employment of its host institution.</p><p>I confirm that I have read and understood the Rules for the EAPCI Education and Training Fellowship Programme for interventional cardiology and that, if an appointment is made, the fellow would be accepted in the Department in connection with the agreement to be arranged with him.</p><p>I confirm that the department will be in a position:  To set up contract (employment, training) with the recipient  To meet any expenditure related to the training programme exceeding the amount provided by the ESC</p><p>Personal Data Privacy The information collected is subject to a computerised process to record, evaluate and track your grant application. The recipients of the data are: • The staff in charge of processing « EAPCI Education and Training Fellowship» applications and, where a grant is awarded, the staff in charge of paying the grant monies. • Persons to whom the request will be sent for review and evaluation. In accordance with the French law N°78-17 of January 6, 1978, amended in 2004, relating to the protection of individuals with regard to the processing of personal data, you have a right to access and rectify information concerning you, which you can exercise by contacting: Customer Services European Society of Cardiology Les Templiers, 2035 Route des Colles 06903 SOPHIA ANTIPOLIS. FRANCE You can also, for legitimate reasons, oppose the processing of data about you.</p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected] Signature of Head of Department: Date: </p><p>Signature of Supervisor: Date: </p><p>Signature of Administrator: Date: </p><p>Please indicate whether health insurance (sickness and accident) is:</p><p>Please indicate the status of the candidate during his/her research period: </p><p>ESC Mission : To reduce the burden of Cardiovascular disease</p><p>The European Heart House – 2035 route des Colles – CS 80179 Biot – 06903 Sophia Antipolis Cedex – France Website: www.escardio.org/EAPCI - Email contacts: [email protected]</p>