International Medical Graduate Alternate Pathway for Radiation Oncology Application for Initial Certification Examinations
Name
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First Name
Middle Name
Last Name
First Name
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Middle Name
Last Name
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Suffix
Gender
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Male
Female
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Birthplace
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City/State/Country
Citizenship
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Country
Country of medical training
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Sponsoring Department
Name of Sponsoring Institution
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ACGME/RRC Program Number
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Name of Sponsoring Department Chair
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First Name
Last Name
Sponsoring Department Chair's Email
example@example.com
Sponsoring Department Chair's Phone Number
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-
Area Code
Phone Number
Sponsoring Department Chair's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SDA Form needs to be filled out by the Sponsoring Department Chair
Sponsoring Department Agreement (SDA) signed by the department chair
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Candidate’s responsibilities (Please check each to acknowledge)
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I acknowledge the need to attend conferences in all areas related to radiation oncology in order to facilitate preparation for ABR exams.
I acknowledge the need for mastering all six core ACGME competencies and attest to this attainment prior to invitation to the Oral Examination.
I will visit the ABR website to review key exam dates, updates in ABR policies, and requirements of the certification process.
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Medical Education
Medical School
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Institution
Location of Medical School
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City/State/Country
Degree Earned
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Year Earned
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Post-medical school training in your country of origin
Clinical Training
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Rows
Institution
City and State
Began
(MM/DD/YY)
Completed
(MM/DD/YY)
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2
Please detail your training in radiation oncology in your country of origin
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Rows
Institution
City and State
Began
(MM/DD/YY)
Completed
(MM/DD/YY)
1
2
3
Please name any other field of residency in which you have trained
Rows
Field
Institution
City and State
Began
(MM/DD/YY)
Completed
(MM/DD/YY
1
2
3
Other Specialty Board Certification Earned
Date Earned
List any medical practice, hospital staff, and/or teaching appointments you have held since medical school
Rows
Position/
Field
Institution
City and State
Began
(MM/DD/YY)
Completed
(MM/DD/YY
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2
3
List any licensure or other regulatory agency certification required. If you are not yet licensed, leave this blank, but remember that you must send an update as soon as you receive your license(s)
Rows
State/Province
Lic./Cert. No.
Expiration Date
(MM/YYYY)
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2
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The Board will assess your status relative to ABR policies and alternative pathways toward board certification only after receipt of required documents
If original documents are in a language other than English, English translation must accompany them.
Current, detailed Curriculum Vitae with specific dates of training
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Verification of medical school training
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Verification of foreign clinical year training with dates of completion
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Verification of foreign radiation oncology residency with dates of completion
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Verification of foreign radiation oncology board certification
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Copy of ECFMG certificate or LMCC certificate
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Copies of USMLE Steps (1-2) score reports
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Copy of USMLE Step 3
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*will be required six months prior to the Oral Examination
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Copy of current medical license
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*will be required six months prior to the Oral Examination
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By signing this application, I agree to the terms and conditions listed above.
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Date Signed
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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