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We are pleased to hear that you are interested in attending a Self-Directed Visiting Fellowship at ProScan Imaging. So we can customize a fellowship that meets your needs and expectations, please fill out this Participant Profile. For your application to be considered, the Participant Profile must be submitted as well as a recent CV. Upon submission of this form, you will be given further instructions on how to send us your current CV.
Name: *
Address: *
City: *
State: *
Zip: *
Country: *
Telephone Number: *
E-mail Address: *
Preferred dates for your fellowship: *
Professional Experiance
Please provide a brief background of your medical imaging experience. *
Modality Experience: *
  No Experience 1 Year Experience 2 Years Experience 3 Years Experience 4 Years Experience 5 Years Experience 10 Years Experience 15 Years Experience More than 15 Years Experience
MRI
CT
Mammography
CAD
Nuclear Medicine
3D
Ultra Sound
Mostly Neurology
Mostly Muskuloskeletal
Other (specify below):
Comment:
Educational Needs Assessment
Please describe your personal educational needs or areas for growth. Your reasons for attending this fellowship: *
Primary Focus (check all that apply): * 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 ProScan Imaging course in the past year? If so, please list the course title and the year attended.
Have you attended a ProScan Imaging Fellowship previously? If so, what year did you attend and what was your focus?
Have you attended a non-ProScan Imaging Fellowship? If so, where and what year did you attend?
If you have any questions, please feel free to contact Michelle Wallace at 513-924-5197.
 




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