Fellowship Program Form

Fellowship Title

Fellowship City

Fellowship State (Abbreviation)

If Neuroimmunology, which of the following is covered: Choose all that apply.

What is the clinical focus of your program?

The fellowship training track is:

Clinical (percentage)

Research (percentage)

Fellowship duration is: (in years)

How many fellows are accepted per year?

Total fellows in training:

What type of trainees do you recruit into your program?

Do fellows take call duty?

Yes

No

OtherOther

Does the fellowship have general neurology clinics?

Yes

No

Our fellow perform rotations in (check all that apply):

Visa sponsorship

Yes

No

What type of Visa?

J1

H1B

Is the fellowship approved by the GME office?

Yes

No

How are fellows funded at your program?

Does the fellow need to secure additional funding?

Yes

No

For how many years is institutional support available to a given fellow?

How many fellows can be supported per year using institutionally available funds?

What materials do you require as part of your Neuroimmunology/MS fellowship application?

What other materials do you require?

When do you begin accepting applications?

When do you typically conduct interviews?

By when have you typically filled your fellowship position/s?

Is there a deadline for the application?

Yes

No

What is the deadline for the application?

Link to the fellowship website:

Contact Information

Completed by:

Name and credentials of the contact person/s:

Name of the institution:

Address

City

State/Province

Zip/Postal

Country

Email Address

Phone Number

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Fellowship Program Form

The fellowship training track is:

Contact Information

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