First Name * Last Name * Birth Date * Gender * Male Female Non-Binary Other Prefer 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 care for bleeding disorders patients, which patient age group do you serve? * 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- to fourth-year fellow Early career physician Up to five years post-fellowship Other
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 select Less than 1 year 1–2 years 3–4 years 5 years Greater than 5 years What percentage of your time is dedicated to bleeding disorders in your current position?* Please select 0-20% 21-50% >51% Other
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."
Are you currently enrolled in a fellowship program? * Yes No
If you are post-fellowship, what specialist qualification have you obtained and when was that completed? *
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? * You are required to attend the entire Academy in Indianapolis, IN from September 23 - 27, 2024, arriving on September 22 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.
