IPNA Fellowship Application

IPNA Fellowship Application
Full name *

First NameLast Name
Email*
example@example.com
Phone number*
Gender*

MaleFemale
Date of birth*

MonthDayYear
Date
Country of birth*
Country of citizenship*
Current address: street*
Current address: city*
Current address: country*
How many years have you lived in current country?*

<11-34-67-10>10
Name of IPNA fellowship training center to which you are applying?*
Proposed start date for fellowship (day/month/year)*

DayMonthYear
day/month/year
Duration of the training program*

6 months7 months8 months9 months10 months11 months12 months
Language spoken (primary/native):*
What language is spoken at host center to which you are applying?*
What is your profiency in language spoken at host center?*

FluentAdvancedBasic/BeginnerNone
Number of pediatric nephrologists in the city you plan to work in after fellowship*

None1-23-56-10>10
Home institution after IPNA fellowship? *
Year you completed medical school*
Year you completed post-medical school training? (residency)*
Are you currently enrolled in a nephrology training program?*

YesNo
Name of training program?*
Level of training center?*

Level 1 (basic)Level 2 (clinical skills)Level 3 (advanced: dialysis)Level 4 (advanced: transplant)
Name of supervisor at training center*
Email of supervisor at training center*
example@example.com
How many months of adult nephrology training have you completed? *

None<11-34-67-12>12
Name of adult nephrology training program?*
How many months of pediatric nephrology training have you completed? *

None<11-34-67-12>12
Name of pediatric nephrology training program?*
How many years have you worked in adult/pediatric nephrology (not inclusive of training)?*

None<11-34-6>6
Name of location(s) you have worked in nephrology*
Facilities and resources at your home institution

	Pediatric (available at home hospital)	Adult (available at home hospital)	Available elsewhere in the city/country and accessible to your pediatric patients	Comments	Plans to initiate at home hospital following fellowship
Intensive Care Unit
Surgery (subspeciality)
Urology (subspeciality)
Cardiology (subspeciality)
Hematology (subspeciality)
Neurology (subspeciality)
Pulmonology (subspeciality)
Percutaneous Kidney Biopsy Procedure
Light microscopy (LM)
Immunofluorescence (IF)
Electron microscopy (EM)
Voiding Cystourethrogram (VCUG)
Sonographic Imaging of the Kidney and Urinary Tract
Urodynamics
Radionuclide Studies
Genetic Testing and Interpretation
Continuous Renal Replacement Therapy
Plasmapheresis
Hemodialysis
Acute Peritoneal Dialysis in Hospital
Chronic Peritoneal Dialysis
Kidney Transplantation

Attachments
CV*

Cancelof
Photo*

Cancelof
Applicant letter*

Cancelof
Host center acceptance letter with training plan*

Cancelof
Letter of nomination by home mentor*

Cancelof
LOR by nephrologist*

Cancelof
LOR relevant local society*

Cancelof
Letter by home institution director guaranteeing employment upon completion of training*

Cancelof
Should be Empty:

IPNA Fellowship Application

Facilities and resources at your home institution

Attachments