Participant Profil for VF - Proscan Imaging

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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: *

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 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? *

If you have any questions, please feel free to contact Michelle Wallace at 513-924-5197.