NPM Fellowship Application 2022

PERSONAL INFORMATION

Select a Stream for Consideration

Choose the cohort you are applying to

Surname *

Given Names *

Address *

City *

Postal code *

Country *

E-mail *

example@example.com

Phone No. *

Immigrant Status *

Please name your country of citizenship *

Funding support *

Yes No

Name of your government funding bureau

Language of instruction at medical school *

English Other

Please specify:

MEDICAL EDUCATION

Degree

Institution

Country

Year granted

PEDIATRIC SPECIALTY EDUCATION (RESIDENCY)

Specialty Degree

Institution

Country

Year granted

ADDITIONAL DEGREE (Ex: MSc / PhD etc)

Addl Degree 1

Institution

Country

Year granted

Addl Degree 2

Institution

Country

Year granted

ENGLISH LANGUAGE PROFICIENCY TEST SCORE

Have you ever taken any English Language Proficiency Test *

Yes No

Name of the test *

Overall Score

Valid until

Have you ever been involved in a teaching role or curriculum development in your career? *

Yes No

If yes, please give details below

Have you ever received academic excellence or awards in your career? *

Yes No

Award 1

Institution

Jurisdiction

Local National International

Award 2

Institution

Jurisdiction

Local National International

Award 3

Institution

Jurisdiction

Local National International

Previous Neonatology Experience (from the date of completion of residency to until now)

Level 3 *

Yes No

Total no. of years *

Specify your role, level of responsibilities, skills, name of the institution and country *

Level 2 *

Yes No

Total no. of years

Specify your role, level of responsibilities, skills, name of the institution and country

Level 1 *

Yes No

Total no. of years

Specify your role, level of responsibilities, skills, name of the institution and country

Any additional training / experience in Neonatology related subspecialities *

Yes No

Description

Institution and country

Dates and total duration

Description

Institution and country

Dates and total duration

Description

Institution and country

Dates and total duration

Do you have any of the following experiences?

Neonatal Transport *

Yes No

Total no. of years *

Specify your role in neonatal transport,, level of responsibilities, skills, name of the institution and country

Growth and Development Clinic *

Yes No

Total no. of years *

Specify your role in this clinic, level of responsibilities, skills,name of the institution and country

Targeted Neonatal Echocardiogram (TnECHO) *

Yes No

Total no. of years *

Specify your role in performing TnECHO, level of responsibilities, skills, name of the institution and country

Neonatal Cranial Ultrasound *

Yes No

Total no. of years *

Specify your role in performing cranial U/S, level of responsibilities, skills, name of the institution and country

Do you have any research publications?

As first author *

Yes No

No. of publications as first author ( original article ) *

Please list pubmed URL links, if not available please cite your papers according to Vancouver style

As Co- author *

Yes No

No. of publications as Co- author ( original article ) *

Please list pubmed URL links, if not available please cite your papers according to Vancouver style

Case reports *

Yes No

No. of case reports *

Please list pubmed URL links, if not available please cite your papers according to Vancouver style

Have you received any research grants or salary awards?

Research Grant *

Yes No

Level *

Local National

Please list successful grants

Have you presented any posters at conferences?

Poster *

Yes No

No. of presentations *

Please list pubmed URL links, if not available please cite your posters according to Vancouver style and mention the conferences against each poster

Have you presented any platform presentations at conferences?

Platform *

Yes No

No. of presentations *

Please list pubmed URL links, if not available please cite your presentations according to Vancouver style and mention the conference name against each presentation

Do you have any administrative experience?

Admin exp. *

Yes No

Please list your administrative responsibilities in respective roles. Please specify the duration in each role and the name of institution and country

Have you been involved in activities that promote health and access to healthcare in your community (Health advocacy)?

Health Advocacy *

Yes No

Please list your health advocacy works you have carried out in your career.

Please attach your CV, letter of intent and credentials, as a single PDF. *

Select File

Neonatal Perinatal Medicine / Clinical Neonatology