The Hip Society Rothman- Ranawat Traveling Fellowship 2020 Application Form

The Rothman- Ranawat Traveling Fellowship

2020 Application Form
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age as of Jan 1, 2020 (yrs):*
Please upload your digital photo

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ELIGIBILITY AFFIDAVIT

VERY IMPORTANT! Read the criteria below carefully. All boxes below must be checked. If any boxes remain unchecked, you may be ineligible to apply for this program. Please contact The Hip Society at hip@aaos.org with any questions.
Initials*

Application Submission Instructions
VERY IMPORTANT! The Hip Society Rothman-Ranawat Traveling Fellowship is a highly competitive program. We receive many applications each year. By following the instructions below, you will ensure successful submission. The Hip Society reserves the right to not consider any application that is not submitted as stated.
1. All applications must be submitted as a complete packet, at one time, and include all of the following items:
  1. The 2020 application form, including the most recent digital photo.
  2. Two (2) signed sponsor letters (both sponsors should be orthopaedic surgeons who are familiar with your work for the past five (5) years, one of whom will be your fellowship director; they may or may not be members of The Hip Society).
  3. Your full updated curriculum vitae, per the requirements specified on page 7 of this form.
2. DO NOT send your information one piece as a time. We will NOT SAVE incomplete applications. The Hip Society staff will NOT PROVIDE follow-up to applicants who try to submit incomplete applications. Submitting a complete application is your responsibility.
3. The Hip Society staff will not interact with your sponsors on your behalf. Obtaining the necessary sponsorship letters is your responsibility.
4. All applications, including all supporting documents as listed above, MUST BE RECEIVED BY THE HIP SOCIETY BY AUGUST 15, 2019, TIME-STAMPED 11:59 PM (US CENTRAL DAYLIGHT SAVINGS TIME).
5. Incomplete applications, or updates to applications, received after the deadline will NOT be considered.
6. Make sure all attached files include your LAST NAME for easy identification and to avoid confusion.
Initials*

Personal Data
Name

First NameMiddle NameLast Name
Degrees:
Country of Birth:
Current Citizenship:
SSN (US):
Institution:
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Office Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Home Email
example@example.com

Sponsors
Name

First NameLast Name
Institution
Name

First NameLast Name
Institution
Please upload two (2) signed sponsor letters (both sponsors should be orthopaedic surgeons who are familiar with your work for the past five (5) years, one of whom will be your fellowship director; they may or may not be members of The Hip Society).
Letter 1

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Letter 2

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Describe the areas of your special interests in orthopaedics

Education
College/ University (Name, City/ State/Province, Country)
Date of Graduation (Month, Year)
College/ University (Name, City/ State/Province, Country)
Date of Graduation (Month, Year)
Postgraduate Education

Please list residency rotations
1st Year
2nd Year
3rd Year
4th Year
5th Year

Additional Education or Fellowship
1.
Type of Education or Fellowship
From (Month/Year)
To (Month/Year)
Name of Director and Fellowship Location
Activity during Fellowship
2.
Type of Education or Fellowship
From (Month/Year)
To (Month/Year)
Name of Director and Fellowship Location
Activity during Fellowship

Eligibility
Date of board certification / recertification:
Date of board certification / recertification:
Member of AAOS?

YesNo
Since (year)
Member of national orthhopaedic society equivalent to AAOS?

YesNo
Since (year)

Hospital Affiliations

(Please list in chronological order, beginning with the most recent)
1.
Academic and Teaching Responsibilities
2.
Academic and Teaching Responsibilities
3.
Academic and Teaching Responsibilities
List Committee appointments at Medical School/ Local Hospitals:

Describe your future career plans
Personal Statement

Please address the following:
- What will participation in this program mean to you professionally and personally?
- What lasting effect will your participation have on your practice of medicine and patient care? How will your patients, and your colleagues, benefit from your experience?
- Why do you believe you should be selected? What might set you apart?

Your curriculum vitae should be current and include the following information:
1. Your full name
2. Current national or institutional committees
3. Special awards (college, medical school, residency, fellowship, following completion of fellowship)
4. List of scientific presentations which you have made as an author or co-author at any national and international meetings (include title of paper, organization, location, and date).
5. List of scientific presentations which you have made as author or co-author at any regional and local meetings (include title of paper, organization, location, and date).
6. List of all the movies, sound slide programs, exhibits, audio or video recordings which you have developed or co-developed. Also list the scientific meetings where each has been presented.
7. List of national, regional and local professional medical organizations or societies to which you belong.
8. List the articles that you have published in peer-reviewed journals (those indexed in PubMed). List the name of the article, journal name, authors, page numbers and the year. Please underline your name and capitalize the name of the journal.
9. List the papers you have published in non-refereed journals. List the name of the article, journal name, authors, page numbers and the year. Please underline your name and capitalize the name of the journal.
10. List textbooks or chapters in textbooks which you have written or edited. Identify title, publisher and the year.
11. List the manuscripts which you have submitted for publication. Identify the article and the journal.
12. Describe clinical and basic research work which is now in progress.
13. Describe any special non-medical and nonacademic achievements or activities and interests which you believe are important to our understanding of your character; i.e., involvement in philanthropic, community, religious, youth, or outreach organizations etc. It is important not to overlook this section in that this helps to give the Committee a better sense of the depth and breadth of your intent outside orthopaedic surgery.
Upload CV here

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Signature of applicant

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The Rothman- Ranawat Traveling Fellowship

ELIGIBILITY AFFIDAVIT

Application Submission Instructions

Personal Data

Sponsors

Describe the areas of your special interests in orthopaedics

Education

Postgraduate Education

Additional Education or Fellowship

Eligibility

Hospital Affiliations

Personal Statement