Please attach/upload a copy of your curriculum vitae (CV)/resume (1–2-pages) * (type: .pdf,.docx, .doc,.txt | size: 2mb) Please attach/upload a Nomination Letter from your HTC Director/Supervisor * (type: .pdf,.docx, .doc,.txt | size: 2mb) HTC Director/Supervisor Name * HTC Director/Supervisor Email Address *
Applicant First Name *
Applicant Last Name *
Birth Date *
Gender *
Male Female Non-Binary Other Prefer Not to Say Current Institution or HTC *
Location of Current Institution or HTC (City, State) *
Telephone Number*
Preferred mobile number to be used for Academy related communications *
Preferred email address to be used for Academy related communications *
Please share an alternative email address that is not likely to change. For example, if your preferred email above is your work email at your institution, we kindly request your personal email (used for backup purposes only) that we may use to contact you. *
When you care for bleeding disorders patients, which patient age group do you primarily care for? *
Please select Peds Adults Both peds and adults Approximately how many persons with hemophilia and/or other bleeding disorders are actively followed at your institution/HTC? *
Current position at time of application *
Second-year fellow Third-year fellow Fourth-year fellow Attending physician * Yes No
If you are currently a fellow, what are your plans post-fellowship? Do you intend to work at an HTC? *
If you are post-fellowship, what specialist qualification have you obtained and when was that completed? *
Indicate your future plans regarding HTC Directorship * Please select I am currently an HTC Director I will become an HTC Director within the next two years (Process has officially begun) I am currently seeking an HTC Director position I have no current plans to become an HTC Director in the near future Undecided Choose the best statement that represents your current/future professional plans * Please select I am currently working at an HTC and plan to continue working at an HTC I am currently working at an HTC but do not plan to continue working at an HTC I am not currently working at an HTC but plan to work at an HTC in the near future I am not currently working at an HTC and do not plan to work at an HTC in the near future I am uncertain about future plans and if they will involve an HTC Other than clinical exposure gained during standard hematology/oncology fellowship training, what other experience do you have in the bleeding disorders space? This can include bleeding disorder-focused research, volunteer experiences, committee participation, teaching experiences, or anything else you’d like to highlight for the Academy selection committee.* For applicants outside of fellowship: What percentage of your time is dedicated to bleeding disorders in your current position? * Please select 0-20% 21-50% >51% Other N/A - I'm currently a fellow.
If other, please explain: *
Please describe your role at your place of work. Examples can include: *
"My FTE breakdown is 80% clinical, 20% research/QI. My clinical time is focused on general non-malignant hematology and my non-clinical time is focused on QI projects."
"I am a new physician at an HTC and spend half my time in clinic (or inpatient hematology service) and the other half of my time involved with hemophilia-focused clinical research."
"As a 3rd year PHO fellow, I spend one day in heme/onc continuity clinic per week, a few weeks per year on inpatient heme/onc service, and the rest of my time working on research in the coagulation research lab."
Please describe any other experience you have with bleeding disorders outside of clinical service or research.* Are you a member of any professional societies? If so, please list them below along with the year you joined and your current status.* Within your work in bleeding disorders, are there any presentations or projects that are particularly meaningful to you? What makes that work stand out from your portfolio of experience?* Please describe to us your research interests in the area of bleeding disorders. Please be specific. * How do you envision your clinical work in bleeding disorders in the future? * What do you hope to gain from participating in the Partners Physician Academy? * How did you initially hear about the Partners Physician Academy? * Please select Referred by Academy past participant Referred by mentor/supervisor Partners Physician Academy Website Partners Physician Academy Social Media Partners Physician Academy Communications (Emails, Flyers, etc.) Conference/Society Involvement (Hemophilia Alliance, ASH, THSNA, etc.) Other
If other: Please indicate how you heard about the Partners Physician Academy *
September 15-19, 2025 , arriving on September 14 and attending the evening welcome reception. Please check box below to confirm understanding and availability. * I confirm my understanding and availability. Print Name (as electronic signature) * Participation is limited to individuals whose applications are complete and are deemed most competitive by the Academy Advisory Board. Incomplete and/or late applications will not be considered.
