THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
DEADLINE FOR APPLICATION: 1 October
Selection will be made and the recipient notified as soon as possible after the deadline so that the fellowship may begin as early as late Fall.
Name of Candidate:
City, State, Zip Code:
Telephone Number (Home and Office):
Date of Birth:
Social Security Number:
Do you desire assistance with locating housing in Washington (Yes or No):
EDUCATION (Non-medical)(Include Institution, Location, Dates, Degree(s)):
MEDICAL EDUCATION (Include Institution, Location, Dates, Degree(s)):
Present Professional Activity:
Anticipated change in present professional activity:
ACOG Fellow (Yes or No):
Date of induction:
ACOG Junior Fellow (Yes or No):
Date of induction:
ABOG certified (Yes or No):
Subspecialty Board certification:
Present teaching position and rank:
Faculty Status (i.e. Full time):
Hospital Staff Memberships; Committee Assignments and Offices Held (List Name, Location and Dates):
Medical Society Memberships; Committee Assignments and Offices Held:
Historical Society Memberships, Committee Assignments, Offices Held:
Historic Research Activities:
I agree to spend full-time daily for five days per week for one month (22 working days) during the award year in the Washington, DC metropolitan area in fulfilling the commitment to the fellowship responsibilities.
PLEASE ATTACH THE FOLLOWING INFORMATION:
1. An updated curriculum vitae including list of publications.
2. A sample of your writing.
3. Name and complete address of three references.
4. Description of your proposed research project, including all of the following:
A. Title of proposed research and definition
B. Objective of proposed research
1. Reasons for undertaking this study D. Statement of research plan
2. Prior investigations performed on the subject by applicant
3. Cite publications related to this study and indicate how proposed work will expand, amend or correct our understanding of the subject
4. Review approach to specific objectives of the study
1. Area of specific information that will be explored E. Narrative introduction to subject, to historical period and to social setting, if appropriate. Present relevant achievements or decisions of the individuals or institutional groups involved, assess their impact upon the medical practice of the period and provide a retrospective assessment of their effect upon the development of ob/gyn.
2. Specific techniques to be used, e.g. library research, oral history, photography, etc.
3. Type of data expected to be obtained and the technique of analysis (e.g. statistical analysis)
4. Anticipated problems in performing study
F. Summary. Provide a summary of the importance of this research and indicate the potential for further developments.
G. Describe how you intend to publicize results.
Please return the completed application and attachments to:
Resource Center - Special Collections
The American College of Obstetricians and Gynecologists
409 12th Street SW
Washington DC 20024
(202) 863-5401 (fax)