Fellowship Programs Common Application (AGP, Urgent Care, Global Health)

All fellowship applicants interested in applying for the programs listed below must register
for the Medicine and Pediatric Specialties Match. See NMRP website for deadlines.

* Indicates an Academic Pediatric Association accredited fellowship training program.

Academic General Pediatric Fellowship Programs

*Baylor College of Medicine Academic General Pediatrics Fellowship
*Boston Children’s Hospital General Academic Pediatrics Fellowship
Children’s Hospital of Philadelphia (CHOP) Academic General Pediatrics Fellowship
*Children's Hospital Los Angeles Academic General Pediatrics Fellowship
*Children’s Hospital of Pittsburgh at UPMC General Academic Pediatrics Fellowship
*Children’s Mercy Kansas City, Academic General Pediatrics Fellowship, Kansas City, MO
*Cincinnati Children’s General Pediatrics Research Fellowship
*Cohen Children's Medical Center Academic General Pediatrics Fellowship
Columbia University Irving Medical Center/ NewYork-Presbyterian Hospital
*Johns Hopkins University Primary Care Research Fellowship Program
*Nemours/Alfred I. duPont Hospital for Children Academic General Pediatrics Fellowship
Nemours/Alfred I. duPont Hospital for Children Weight Management Fellowship
*New York University School of Medicine Fellowship in Primary Care Research – Academic General Pediatrics
Stanford School of Medicine Fellowship in Academic General Pediatrics
University of Minnesota Interdisciplinary Research Training in Children & Adolescent Primary Care (IRT-CAPC)
*University of Rochester Academic General Pediatrics Fellowship Program
Vanderbilt University Medical Center
University of Washington School of Medicine, Child Health Equity Research Program for Post-doctoral Trainees (CHERPP-T)

Acute/Urgent Care Fellowship Programs

*Children's National Pediatric Urgent Care Fellowship
Children's Hospital of Pittsburgh Pediatric Acute Care
Emory University Pediatric Urgent Care fellowship
*Nationwide Children's Academic Pediatric Acute Care Fellowship
Phoenix Children's Pediatric Acute Care Fellowship

Global Health Fellowship Programs

*Pediatric Emergency Medicine Global Health Fellowship, Baylor College of Medicine Department of Pediatrics & Texas Children's Hospital, Houston, Texas
*University of Utah Global Health Fellowship
*Children's Colorado Global Health Fellowship

Fellowship Programs Common Application

"*" indicates required fields

Step 1 of 8

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Personal Information

Name*

First Middle Last Suffix

Previous Last Name

Date of Birth*

MM slash DD slash YYYY

Email*

Phone*

Emergency Contact Name

Emergency Contact Phone

What type of program(s) are you applying to?*

Please check all that apply

Academic General Pediatric

Acute/Urgent Care

Global Health

Mailing Address

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Citizenship

Citizenship*

US Citizen

US Permanent Resident

Other

If you are a foreign national outside the US, or currently in the US on a valid visa status, please note the programs that accept Visa applicants and respond to the questions below. IF NOT A FOREIGN NATIONAL, SKIP TO THE SECTION LABELED “Education” below the ECFMG/TOEFL scores.

Programs that accept Visa applicants:

Will you need a “visa sponsorship” through the teaching hospital (J1, H1B, etc.) to participate in US fellowship training?*

Yes

Please specify type of Visa*

Is your medical school listed on the approved list for state licenses to which you will be applying?*

Yes

Unsure

If you are unsure, please contact the programs to which you are applying. Obtaining state license, for the state in which you will be training, is mandatory to begin fellowship.

Did you train at a foreign medical school?*

Yes

ECFMG/TOEFL Scores

Please provide documentation for your ECFMG and/or TOEFL scores.

Max. file size: 128 MB.

Education and Training

College/University

College/University*

From*

To*

City, State*

Degree*

Medical School

Medical School*

From*

To*

City, State*

Degree*

Internship

From

City, State

Degree

Residency

Residency*

From*

To*

City, State*

Degree*

Other Training

From

City, State

Degree

Was your medical education/training extended or interrupted?*

Yes

If YES, please note the date and comment*

Licensure Information

This section allows entries for each of your state medical licenses.

Have you passed the USMLE Step 3?*

Yes

Current Medical License
Note: If you do not have a current medical license, go to the next page to skip to the “Board Certification” questions.

Entry 1

State

License Number

License Type

Expiration Month/Year

Entry 2

State

License Number

License Type

Expiration Month/Year

DEA Number (DEA is for US Medical License holders only.)

DEA Registration Number

Expiration Month/Year:

Has your medical license ever been suspended, revoked, or voluntarily terminated?

Yes

If YES, please note the date and comment

Have you ever been named in a malpractice case?

Yes

If YES, please note the date and comment

Is there anything in your past history that would limit your ability to be licensed or would limit your ability to receive hospital privileges?

Yes

If YES, please note the date and comment

Board Certification

Are you Board Certified?*

Yes

If NO, will you be Board Eligible by the beginning of the fellowship?*

Yes

Board Name

Are you Board Certified/eligible for more than one Board?*

Yes

If YES, will you be Board Eligible by the beginning of the fellowship?*

Yes

Board Name*

Miscellaneous

Are you able to carry out the responsibilities of a fellow at the specific training program to which you are applying, including the functional requirements, cognitive requirements, interpersonal and communication requirements, and attendance requirements with or without reasonable accommodations?*

Yes

If NO, please explain*

Letters of Recommendation

Please provide three (3) letters of recommendation. If you are within five years of residency training, one letter must be from your Residency Program Director or his/her/their designee. Make sure each letter writer receives a Confidential Reference Report. A report must be submitted alongside each letter of recommendation. Letter writers should submit their letters of recommendation along with a Confidential Reference Report via email directly to each Fellowship Program Director. Please see Appendix 1 for a comprehensive list of email addresses.

Reference 1

Reference 1 Name and Title*

Reference 1 Contact Information*

Please provide Address, Email, and Phone

Reference 1 File*

Max. file size: 128 MB.

Reference 2

Reference 2 Name and Title*

Reference 2 Contact Information*

Please provide Address, Email, and Phone

Reference 2 File*

Max. file size: 128 MB.

Reference 3

Reference 3 Name and Title*

Reference 3 Contact Information*

Please provide Address, Email, and Phone

Reference 3 File*

Max. file size: 128 MB.

Personal Statement

Please attach a one-page personal statement explaining why you want to complete a fellowship in Academic General Pediatrics, Urgent Care, or Global Health. Please include the following: a description of your career goals, how the fellowship may assist you in achieving them, your scholarly/research interests, and how you envision your career five years after completion of this fellowship. You may want to include how past experiences have influenced your decision to apply and mention special areas of interest. (Please include your name on the attachment.)

Personal Statement*

Max. file size: 128 MB.

Attestation

Consent*

I certify that the information contained in this application is complete and accurate to the best of my knowledge. I understand that any false or missing information may disqualify me from consideration for a position, or if employed, may constitute cause for termination from the program. I also understand and agree that the data included in this application may be shared within the fellowship programs to which I am applying.

I agree with the above attestation.

Supplemental Biographical Information

The information requested is for statistical purposes only and will not be used during consideration of the application.

Place of Birth

Gender

Ethnicity

Of Hispanic or Latino origin (a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race).

Not of Hispanic or Latino origin

Race

Black or African American: A person having origins in any of the original groups of Africa.

Asian or Asian-American: Includes persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian sub-continent (e.g., Cambodia, China, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam).

American Indian or Alaskan native: Includes persons having origins in any of the original peoples of North America and South American (including Central America), who mains tribal affiliation or community attachment.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa or other Pacific Islands.

White: Includes persons having origins in any of the original peoples of Europe, North Africa or the Middle East.

Prefer not to say

Disadvantaged background

An individual from a disadvantaged background is defined as someone who: Comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession. OR Comes from a family with an annual income below a level based on low-income thresholds according to family size published by the US Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of Health and Human Services for use in health professions and nursing programs.

Yes

Fellowship Programs Common Application (AGP, Urgent Care, Global Health)

Academic General Pediatric Fellowship Programs

Acute/Urgent Care Fellowship Programs

Global Health Fellowship Programs

Fellowship Programs Common Application

Personal Information

Mailing Address

Citizenship

Education and Training

Licensure Information

Board Certification

Miscellaneous

Letters of Recommendation

Personal Statement

Attestation

Supplemental Biographical Information

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