Applicant Information Form for Pediatric EP Fellowship Training Programs
From the PACES Training Program Directors
IMPORTANT NOTE: This applicant information form is NOT an application submission for fellowship. This is to provide information on the applicant pool to the PACES-TPDs and for further communications during the application process. It will not be sent to any specific training programs.
Name
*
First Name
Last Name
Email
*
example@example.com
What type of EP fellowship are you applying for?
*
Traditional Pediatric EP
Non-invasive Pediatric EP
Adult Congenital Heart Disease (ACHD) EP
Other
You are applying for an EP Fellowship position starting July of what year?
*
Year (YYYY)
Which of the following best describes your current role?
*
Categorical pediatric cardiology fellow
Practicing as an attending physician
Other
At what institution do you currently practice?
*
Does your current institution offer an advanced fellowship in Pediatric EP?
*
Yes
No
Will you be accepting (or have you already accepted) a fellowship position at your current institution?
*
Yes
No
What is your current citizenship/visa status?
*
United States Citizen/permanent resident
Canadian Citizen/permanent resident
US Visa
Canadian Visa
Other
Type of Visa if Applicable
In agreement with the PACES 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.
Which of the following best describes your ethnicity?
*
American Indian or Alaska Native (e.g., Navajo Nation, Blackfeet Tribe, Inupiat Traditional Gov't., etc.)
Asian or Asian American (e.g., Chinese, Japanese, Filipino, Korean, South Asian, Vietnamese, etc.)
Black or African American (e.g., Jamaican, Nigerian, Haitian, Ethiopian, etc.)
Hispanic or Latino/a (e.g., Puerto Rican, Mexican, Cuban, Salvadoran, Colombian, etc.)
Middle Eastern or North African (e.g., Lebanese, Iranian, Egyptian, Moroccan, Israeli, Palestinian, etc.)
Native Hawai`ian or Pacific Islander (e.g., Samoan, Guamanian, Chamorro, Tongan, etc.)
White or European (e.g., German, Irish, English, Italian, Polish, French, etc.)
Prefer not to say
Other
Which of the following best describes your gender identity?
*
Male
Female
Non-binary / third gender
Prefer not to say
Other
Do you consider yourself a member of an under-represented minority group?
*
Yes
No
Once you submit this form, an email conformation will be sent to you with a PACES-TPD common initial application form as a PDF attachment. Not all programs will accept this application, but a large majority will. Some programs may have their own specific application forms that they require. You must check with each individual program to see if they will accept it.
If you are accepting/have accepted a fellowship position at your current institution OR you are applying for an ACHD EP fellowship, you can ignore the attached PACES-TPD common initial application form PDF.
If you do not receive this email confirmation, please send an email to pacestpd@gmail.com. For more information about the PACES EP fellowship Application Process, please visit: https://www.pacesep.org/fellowshipapp/
Submit
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