ACG Logo

American College of Gastroenterology
P.O. Box 342260
Bethesda, MD
20827-2260
(301) 263-9000

GRADUATING FELLOW QUESTIONNAIRE

* = Required

Personal Profile

*First Name *Last Name
* MD DO PhD Other
*Mailing Address
Mailing Address 2
*City *State
*Zip/Postal Code *Country
*Home Phone Office Phone
Cell Phone    
*E-mail
*Preferred Contact E-Mail Home Phone Office Phone Cell Phone
*U.S. Citizen? Yes No
If no, indicate nationality Visa Status
First Language Second Language

Professional Profile

University Degree Date Awarded
Medical School Degree Date Awarded
Internship Institution Inclusive Dates
Residency Institution Inclusive Dates
*Fellowship Institution Inclusive Dates
Other Institution Inclusive Dates
Board Certified Specialty(s)

*Completed training in the following areas/procedures:

Clinical GI Hepatology Nutrition Research (Clinical/Academic)
Pediatrics Surgery Motility Laparoscopic Surgery
EUS ERCP Standard Endoscopy (COL, EGD)
Special Therapeutic Procedures Wireless Capsule Endoscopy
Other (please list)  

Have you been involved in any research or clinical investigations? Yes No

Publications/Presentations/GI Honors? (please list and limit to 2000 characters)

Employment Information and Interest

*Type of Position        
Private Practice Academic Corporate
    Practice with 5 or fewer MDs       Pure Clinician      
    Practice with 6 or more MDs       Clinical Educator    
    Multi-Specialty Group       Basic Science Researcher    

 

*Please select the area(s) in which you wish to locate:
Northeast (CT, MA, ME, NH, NJ, NY, PA, RI, VT)
South (AL, AR, DC, DE, GA, FL, KY, LA, MD, MS, NC, SC, TN, VA, WV)
Midwest (IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, OK, SD, TX, WI)
West (AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY)
Canada
Will you be flexible in locating elsewhere?
Yes No
What parts of the country would you prefer to avoid?
What is the earliest date you can start?
*Will you be attending the ACG Meeting?
Yes No
If yes, please indicate times you would be available for a personal interview
Sunday, Oct 5th
Monday, Oct 6th
Tuesday, Oct 7th
Wednesday, Oct 8th
*How can you be contacted during the meeting?
*Would you like to be contacted after the meeting with copies of employer postings?
Do not contact me after the meeting
E-mail postings that match my criteria
Mail me a list of all posted positions after the meeting

Resume (must be Microsoft Word document)