ࡱ> |~{3 bjbjCC -B!!oLl*%%%8%, &t*=h&&:&&&'' '^=`=`=`=`=`=`=$G? gA='''''=g+&&=g+g+g+'.&&^=g+'^=g+g+U2R:<&& 0T*~%(@~;<\=0=;f;BW(;B<g+**I  Mini-Fellowship Program at UCLA Application Form Please indicate the date you are applying for: ______ October 17-19, 2007 ______ February 20-22, 2008 ______ June 25-27, 2008 Please type or print clearly. Attach additional sheets if more space is needed. Personal Information Last Name First Name MI E-mail Address Mailing Address City State Zip Telephone Present Position(s) Institution Specialty Area (s) Special Clinical or Teaching Interest(s) BACKGROUND INFORMATION Have you had any training in geriatric medicine? If yes, please describe briefly. Have you participated in any geriatrics mini-fellowships or courses? If so, which ones and when? Previous Course Date Previous Course Date Please rank in order your choice of Fellowship Tracks (1 being your top choice): _____ Generalist _____ Hospitalist _____ Palliative Care _____ Skilled Nursing Facility FACULTY/TEACHING APPOINTMENT Do you currently have a faculty/teaching appointment? _____ Yes _____ No If yes, please specify: ______ to ______ _____________________________________________________ Year Year Institution Location MEDICAL EDUCATION Medical School Location Graduation Date CERTIFICATIONS Specialty Board Date Specialty Board Date POST MD TRAINING Residency ______ to ______ _____________________________________________________ Year Year Institution Location Subspecialty Training ______ to ______ _____________________________________________________ Year Year Institution Location Specialty LICENSURE State License Number Expiration Date WORK EXPERIENCE Please list relevant teaching or clinical positions held. Position TitleInstitutionDates Employed PROFESSIONAL ORGANIZATIONS Please list memberships in professional organizations and societies. Name of Organization/SocietyMembership Dates ADDITIONAL INFORMATION Please specify how many percent of your patients are in the following age groups (total=100%): Under 65 65-74 75-84 Over 85 Please specify how many percent of your time is spent on each of the following activities (total=100%): Teaching Clinical care Administration Research Other (specify) What percentage of time (if any) do you spend training students, residents, fellows or others involved in patient care at the following institutions? Acute care hospital Ambulatory care facility Long-term care institution Long-term non-institutional care (e.g. home care, assisted living) Other (specify) Are you involved in creating the teaching curriculum at your institution? If so, in what capacity? What interested you most about participating in the Mini-Fellowship Program at UCLA? (Check all that apply.) Desire to improve teaching skills Desire to improve geriatrics clinical skills Interest in specialized training New or expanded teaching role CME credit Other (specify) If selected to attend the Mini-Fellowship, will you need to reserve a hotel room? Yes No How did you hear about the Donald W. Reynolds Mini-Fellowship Program at UCLA? (Check all that apply.) Brochure or flyer MPGMG Newsletter Email from Medical School Dean Website Referral Other (specify) LETTER OF SUPPORT Please provide a letter of support from your department chair, dean or division chief with your application. Please submit (via fax or mail) your completed application and letter of support to: Anne Hu, MPH Reynolds Program Coordinator David Geffen School of Medicine-UCLA Division of Geriatrics 10945 Le Conte Avenue, Suite 2339 Los Angeles, CA 90095-1687 Tel: (310) 312-0531 Fax: (310) 312-0546  HYPERLINK "mailto:AnneHu@mednet.ucla.edu" AnneHu@mednet.ucla.edu SIGNATURE X APPLICANT DATE Revised  DATE \@ "M/d/yy" 7/20/07 Page  PAGE 1 of  NUMPAGES 4 {./1/0cde|}67MNcfgɽɽɽxxp>*CJOJQJ CJOJQJ CJOJQJ 5CJ\ 5CJ\ CJOJQJ CJOJQJ5;CJOJQJ\ CJOJQJOJQJ 5>*CJ5CJOJQJ\^JCJOJQJ^J5\5OJQJ\^J5CJOJQJ\^Jj5CJU\^J5CJ\^J,{./1 & p@ P |) !|)$d&d NP  |) !|) $ d|)a$ ^`$a$o/0cde|} |)$dN |)$d &d N P  |)&d P  & p@ P |) !|)&d P 67MNdfg  & p@ P |)$d N    |)$d &d N P  $d &d N P  & p@ P |)$d N <=w}! " & 8 9 h i j k z {   I J K c k n / 0 1 2 B C ~ ! ۷ԷԷ5CJOJQJCJ5 CJOJQJCJOJQJ^J CJOJQJCJ CJOJQJ CJOJQJOJQJ>*CJOJQJ CJOJQJH<=! 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