xtra – Partners Physician Academy

First Name *

Last Name *

Birth Date *

Gender *
MaleFemaleNon-BinaryOtherPrefer Not to Say
Institution or HTC *

Mailing Address *

Telephone Number

Mobile/Cell Phone Number *

Email Address *

Please attach/upload a copy of your curriculum vitae (CV)/resume (1–2-pages) * (type: .pdf,.docx, .doc,.txt | size: 2mb)

HTC Director/Supervisor Name *

HTC Director/Supervisor Email Address *

Please attach/upload a Nomination Form from your HTC Director/Supervisor * (type: .pdf,.docx, .doc,.txt | size: 2mb)

When you take care of bleeding disorders patients, for which age groups will you be caring? *

Current Position *
Second- to fourth-year fellowEarly career physicianUp to five years post-fellowshipOther

How many years post-fellowship *

How many years of relevant experience in the bleeding disorders space do you have to date? (e.g., clinical care or research experience – include years spent in fellowship) *

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."

Are you currently enrolled in a fellowship program? *
YesNo

If yes, what year are you currently in? *

If yes, is it Pediatric, Adult, or Med-Peds? *

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? *

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? *

You are required to attend the entire Academy in Indianapolis from September 18 – 22, 2023, arriving on September 17 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) *

Date (mm/dd/yyyy) *

Participation is limited to individuals whose applications are complete and are deemed most competitive by the Faculty. Incomplete and/or late applications will not be considered.

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2023 Partners Physician Academy | September 18-22, 2023

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