MAP–ORSI Fellowship Application Form

MAP–ORSI Fellowship Application Form

Apply for the 7-day proficiency-based robotic urology fellowship at ORSI Academy, Melle, Belgium. 5 positions are available and applications are reviewed on a rolling basis. Please complete all sections fully and accurately; all fields marked * are required.
A. Personal & Contact Information
Title
First Name
Last Name
Date of Birth

MonthDayYear
Date
Gender
Country of Citizenship
Country of Current Practice
Email Address
example@example.com
Phone / WhatsApp
Please enter a valid phone number.Format: (000) 000-0000.
B. Medical Training & Current Practice
Primary Medical Degree
Urological Qualification
Year of Urological Qualification
Awarding Institution / Body
Current Institution / Hospital
Department
Designation / Grade
Years in Independent Urological Practice
C. Clinical Experience
Open Urologic Cases (last 24 months)
Endoscopic Cases (TURP/TURBT/URS) (last 24 months)
Laparoscopic Cases (last 24 months)
Laparoscopic Procedures Performed

Other
Prior Robotic Surgery Experience
Prior Robotic Experience Details (platform, procedures, case numbers)
D. Robotic Environment & Fellowship Fit
Does your institution currently have a robotic platform?
Robotic Platform
Robotic Cases per Month at Your Centre
Post-Fellowship Implementation Plan
Robotic console operation (basic)
RARP (robotic radical prostatectomy)
RAPN (robotic partial nephrectomy)
Robotic intracorporeal suturing / anastomosis
Robotic complication recognition & management
E. Fellowship Goals & Motivation
Procedures You Most Want to Learn (priority order)
Statement of Purpose (max 300 words)
Preferred Fellowship Period
Alternate Period
How did you learn about this fellowship?

Other
Accessibility / Special Requirements
F. Declarations & Consents
Declaration of accuracy and completeness
Understanding of costs and responsibilities
Consent to anonymised data use for research
Acceptance of selection limits and final decision
Should be Empty:

MAP–ORSI Fellowship Application Form

A. Personal & Contact Information

B. Medical Training & Current Practice

C. Clinical Experience

D. Robotic Environment & Fellowship Fit

E. Fellowship Goals & Motivation

F. Declarations & Consents