INTERVENTIONAL PULMONOLOGY FELLOWSHIP APPLICATION FORM AND EVALUATION DOCUMENT FOR THE SELECTION OF FELLOWSHIP × Thank you for your submission! × There was an error with your submission. Please try again. × Invalid form submission. Reason: Family Name: First Name: Country: Malaysia Others If Others, please fill in: Address: Hospital where you currently work ( Private practice / Academic Institution / Government Hospital ): Medical Degree: Scientific societies of which you are a member: Email: Mobile Phone: Possibility of professionally developing the acquired skills Potential of establish IP practice in your country Do you plan to develop an IP activity as part of your private practice? Do you have any sponsors for the program? Medical specialty (Pulmonary/Respiratory Thoracic Surgery/Other): Previous experience in Interventional Pulmonology training ( Specify: year, city, country, period ): Interventional Pulmonology courses ( Specify: year, city, country, period): Communications / Lectures / Presentations in national / international congresses and conferences (Attach supporting documents in *.pdf format): Publication on IP in national/international journals (Attach supporting documents in *.pdf format): Research grants related with IP: Time worked in basic Bronchoscopy (years): Time worked in an Interventional Pulmonology Unit (years): Total number flexible bronchoscopies in your life: Total number rigid bronchoscopies in your life: Thoracic Endoscopy Flexible bronchoscopy Linear EBUS Radial EBUS Electromagnetic Navigation Bronchoscopy Rigid Bronchosocopy Pleural procedures Pleural drainage Tube placement Thoracoscopy Pleurodesis Pleural biopsy Do you have the resources to be able to pay for the stay and expenses related to the program? Yes No Do you have problems in your country to obtain a visa to reside in Malaysia? Yes No Does your personal and family situation allow you to complete the 3-month training program? Yes No Upload CV ( *.pdf only ) Suggested Date for Fellowship Period: Send
