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Society of Interventional Radiology FSIR Application
3975 Fair Ridge Drive, Suite 400 North, Fairfax, VA 22033 Email: Membership@SIRweb.org

Instructions and Information

This is the online SIR Fellowship application. The Fellows' Affairs Committee will consider and review all completed applications. A complete application consists of:

this completed and submitted form. You will be able to save your progress with this online application and will be able to review your application before submitting.
a copy of your CV. You may upload this document within the form. Please name your CV file as your last name (eg JONES_CV).
a cover letter that includes documentation supporting the criteria that you are applying under.
Photocopy of your Board Certificate or equivalent certification
2 letters of recommendation from current SIR Fellows. Please enter their name in the application. You may forward this link to them: http://www.tfaforms.com/283150.

To be considered for induction at the Annual SIR Fellows' Business Meeting and Dinner, all applications must be completed by December 31st of the calendar year prior to the meeting.

Contact the SIR Membership Department at Membership@SIRweb.org with any additional questions.

General Applicant Information

First Name

Middle Initial

Last Name

Designation (MD, DO, Other)

Email address

Gender

MaleFemale

Categories of FSIR

Select which level of SIR Fellowship you are applying for:

Active FellowAssociate Fellow

Requirements for Active or Associate Fellowship

Applicants shall be current SIR Active or Associate members of the Society who have made significant contributions to the field of Interventional Radiology and to the Society.
Fellow candidates shall have been a practicing member in good standing of the Society for at least eight contiguous years. This does not include membership during "member-in-training" years.
The candidate shall have made a significant contribution to the field of Interventional Radiology as well as contribution(s) to the Society as determined by the policy set forth by the Fellows' Affairs Committee. When evaluating candidates for Fellowship, the Fellows Affairs' Committee shall review the totality of the candidate's contributions on behalf of Interventional Radiology and the Society. Fellowship shall be awarded based on a long and consistent history of activities.

Individuals practicing outside of the United States shall have the option of applying as an
Active or Associate Fellow.

Click here to review more information about the criteria and requested supported documentation.

CURRENT PRACTICE INFORMATION

Hospital/Practice/Institution

Address

Address 2

City

State

Zip-Postal Code

Country

EDUCATION

	School	City	State	Graduation Year	Degree(s)
Undergraduate
Other Graduate
Medical School

Additional notes/comments about education

INTERNSHIP AND RESIDENCY(IES)

INTERNSHIP

Program Director

Program Name

City

State

Start Year

End Year

RESIDENCY

Specialty

Program Director

School

City

State

Start Year

End Year

ADDITIONAL RESIDENCY

Specialty

Program Director

School

City

State

Start Year

End Year

Degree(s)

Additional notes/comments about internship and residencies

FELLOWSHIP

Specialty

Program Director

Program Name

City

State

Start Year

End Year

Additional training years/comments about your fellowship

Page 3

SPECIALTY BOARD CERTIFICATION/RADIOLOGICAL QUALIFICATIONS

	Primary Board Certification	Name of Specialty Board	Year of Certification
1.
2.
3.

Have you obtained a CAQ? If so, please provide year.

CURRENT MEDICAL LICENSURE

	State	License Number	Date of Certification
1.
2.

PAST PRACTICE ACTIVITIES

	Hospital	City, State	Title	Hrs/W	Dates: From/To

Additional notes/comments about your practice activities

Estimate the percentage of your time practicing clinical IR.

PROFESSIONAL SOCIETIES

Please indicate if you are a member of the following societies:

AMAAHARSNAACR

Other (please list):

Please use the spaces below to detail your membership and offices held in all professional societies and associations.

	Society/Association	Type of membership/ office	Dates: From/To

Other Qualifications

Include any information concerning special qualifications or relevant data not included above.

COMMITTEE/ANNUAL MEETING INVOLVEMENT

Please list any SIR committees you have served on (past and present). Please also include the name of the chair of the committee you served at the time of your involvement.

Please list any SIR Annual Meeting contributions/involvement (include year).

SPONSORSHIP

Supporting letters from current SIR Fellows are very important components of the nomination package. As a general rule, more weight will be given to letters that provide substantial information as opposed to a brief or pro-forma letters. Sponsors should be encouraged to provide detail in their letters of your accomplishments. Although at least two letters are required, more are certainly allowed, particularly if they document significant or unusual experience, or service not specifically spelled out in this document, but felt by the nominee to be applicable.

Sponsors must provide a letter of recommendation by using SIR's online Letter of Recommendation form found here: http://www.tfaforms.com/283150

It is your responsibility to encourage the submission of your letters.

	Name of Fellow/Sponsor	Institution	Sponsor's Email address
1.
2.

APPLICANT FULFILLS WHICH OF THE THREE CRITERIA:

Please indicate of which of the criteria you are applying under (you may select more than one):

1. First author of at least eight significant papers on cardiovascular and interventional subjects in refereed journals2. Directly involved in the full-time supervision and training of residents and/or fellows in cardiovascular and interventional radiology for a minimum of eight years3. Is an exceptional leader or teacher through his/her service to cardiovascular and interventional radiology

Cover Letter info

The Fellow's Committee requests that you submit a letter in support of your application outlining your qualifications. In evaluating candidates for Fellowship, the committee will review the totality of the candidate's contributions on behalf of Vascular and Interventional Radiology.

It should be understood by the candidate that Fellowship will be awarded for a long and consistent set of activities. The items in this section should be looked at as general guidelines. They do not guarantee that a nominee will be granted fellowship. They are provided as examples in an attempt to provide general direction and consistency to the review process.

If you are applying under Criteria 1:

List at least eight of the significant papers. For each paper, include the following information:

- Title

- Publication

- Date of Publication
- Authors
- Your Role in the Publication (eg, primary author, primary author supervising a fellow/resident)

Please describe the research with which you have been involved. Include a list of the first author significant publications on interventional subjects that have been published in peer-reviewed journals and additional publications which you feel are of importance.

If you are applying under Criteria 2:

List the month/year and total duration of time you spent in full-time supervision and training fellows and residents in interventional radiology. This cumulative time must be at least eight years. Letters of verification for each program listed must be supplied by the head of that department. Include the following information for each program.

- Program name

- Department

- Title/Responsibilities

- Start Date

- End Date

- Time in this position (number of years and months)
- % of practice time devoted to teaching IR (# of hours/week devoted to IR training)

Please describe your involvement with teaching medical students, residents and fellows in Interventional Radiology. Of particular interest are your involvement in the program (i.e. fellowship director), number of residents, number of fellows and teaching time commitment.

If you are applying under Criteria 3:

Please describe your involvement in the Society of Interventional Radiology and/or your service to the field of vascular and interventional radiology. In particular, please specifically describe your SIR committee involvement, volunteer involvement at the annual meeting (workshops, plenary session, etc.), and your local/regional involvement in advancing the field of interventional radiology.

Click here to review more information about the criteria and requested supported documentation.

You may use this space to compose and submit your cover letter or you may upload a document that will be submitted to the committee. Please include your LAST NAME in the document name. (e.g.JONES_Cover_letter.doc)

If you are uploading your cover letter, please include your LAST NAME in the document name. (e.g.JONES_Cover_letter.doc or JONES_Cover_letter.pdf)

CURRICULUM VITAE

Please upload the most recent copy of your CV. Please include your LAST NAME in the document name. (e.g.JONES_CV.doc or JONES_CV.pdf). You may also email your CV to Membership@SIRweb.org.

BOARD CERTIFICATION

Please upload a copy of your board certificate or equivalent. (e.g.JONES_Board_Cert.doc or JONES_Board_Cert.pdf)

Signature

I verify that the information in this SIR Fellowship application is accurate.

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