Participant Profile We are pleased that you are interested in attending a Self-Directed Visiting Fellowship at ProScan Imaging.   The following Participant Profile must be completed, in addition to sending a current CV, copies of your medical license, NPI number, and picture ID for your application to be considered. A link to submit your CV will be available, once you complete the Participant Profile. Name: * Address: * City: * State: * Zip: * Country: * Telephone Number: * E-mail Address: * NPI#: Medical License - Country of Origin: * Medical License - Number: * Contact Number for licensing board/organization: * Preferred dates for your fellowship: * Professional Experiance Please provide a brief background of your medical imaging experience so we can customize a fellowship that meets your needs and expectations. * Modality Experience: *   No Experience 1 Year 2 Years 3 Years 4 Years 5 Years 10 Years 15 Years More than 15 Years MRI CT Mammography CAD Nuclear Medicine 3D Ultra Sound Mostly Neurology Mostly Muskuloskeletal Other (specify below): Comment: Educational Needs Assessment Please describe your educational needs/areas for growth that you would like to develop: * Primary Focus: * please select ... Muskuloskeletal Orthopaedic Neurology Cardiac Breast MRI CCTA Other (specify below) Comment: Secondary Focus: * please select ... Muskuloskeletal Orthopaedic Neurology Cardiac Breast MRI CCTA Other (specify below) Comment: Objectives What do you expect to gain from your participation in this educational activity? (Check all that apply) * To become more familiar with MR imaging and to refresh my skills To become more familiar with MR imaging and to broaden my skills To increase my expertise in subspecialty MR (please epecify below) Comment: Other Information Have you attended a past ProScan Imaging course? If yes, please list the course title and the year attended. * Have you previously attended a ProScan Imaging Fellowship? If yes, what year did you attend and what was your focus? * Have you attended a non-ProScan Imaging Fellowship? If yes, where and what year did you attend? * Please fax copies of CV, medical license, NPI number, and picture ID to 513-352-9423. If you have any questions, please feel free to contact Leslie Combs at 513-924-5197.