Advanced Fellowship Applicants

Dear Applicants,

We are excited to learn of your interest in advanced training in Pediatric Cardiac Intensive Care. As you prepare your application materials, we ask that you take a short period of time to complete the following questionnaire. These questions are designed to improve our general understanding of those who will make up the future of our field; your answers will be pooled and will not impact your candidacy for fellowship training. Thank you for participating in this process.
1. At what institution do you currently practice?*
Please try to complete this form only once. If you are repeating your registration for any reason, please note this in your answer to Question 1 by adding the term “repeat entry” after your institution’s name.
2. In what categorical specialty/specialties have you trained (select all that apply)*

Pediatric CardiologyPediatric Critical Care MedicineNeonatologyPediatric AnesthesiaOther
If Other Please Describe:
3. What is your current citizenship / visa status? (select one)*

United States citizen / permanent residentCanadian citizen / permanent residentUS VisaCandian VisaOther
Type of Visa If Applicable:
If Other Please Describe:
4. During the year immediately preceding your Advanced Fellowship, which of the following best describes your role?*

Completing categorical trainingPracticing as a physician in an academic institutionPracticing as a physician in a non-academic institutionOther
If Other Please Describe:
5. What is the date on which you completed this form? *

MonthDayYear
Date
In agreement with the PCICS Statement on diversity, equity, and inclusion, we are committed to the development of a diverse and inclusive workforce. The following questions are optional and your responses will be kept anonymous, however, your responses will be used in aggregate to raise awareness of the demographics of our field.
6.Which of the following best describes your ethnicity?

African AmericanLatino/a/xAsian/Pacific IslanderCaucasianDecline to StateOther
If Other Please Describe:
7. Which of the following best describes your gender?

FemaleMaleNon-BinaryOtherDecline to State
If Other Please Describe:
8. Do you consider yourself a member of an under-represented minority group?

YesNo
Should be Empty: