International Medical Graduate Alternate Pathway Application for Interventional Radiology/Diagnostic Radiology (IR/DR) Certification
First Name
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Middle Name
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Name
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First Name
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Email
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Street Address
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Date of Birth
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Birthplace
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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
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Sponsoring Department Chair's Email
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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 interventional and diagnostic radiology 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 Certifying Exam.
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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Institution
City and State
Began
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Completed
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Please detail your training in diagnostic radiology in your country of origin
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Institution
City and State
Began
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Completed
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Please name any other field of residency in which you have trained
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Institution
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Other Specialty Board Certification Earned
Board
Date Earned
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).
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State/Province
Lic./Cert. No.
Expiration Date
(MM/YYYY)
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The Board will assess your status relative to ABR policies and alternate pathways toward board certification only after receipt of required documents
If original documents are in a language other than English, an 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 radiology/interventional residency with dates of completion
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Verification of foreign radiology 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 Certifying Exam
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Copy of current medical license
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*Six months prior to the Certifying Exam you will be required to update your license information
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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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