Southern Society for
Clinical Investigation

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Phone: [VAR_PRACTICE_PHONE]

Fellow Nomination Form

Fellowship Track
First Name
Middle Name
Last Name
Suffix
Degree
Date of Birth
Academic Rank
Position/Title
Department
Division
Institution
Street Address 1
Street Address 2
City
State
Zip Code
Telephone
Fax
Email Address
Specialty
Subspecialty
Medical School Name
Medical School City and State,
Post-Graduate Training Type
Post-Graduate Training Program
Post-Graduate Training Dates
Professional Certification
Date of Certification

NOMINATED BY

*Nominating Individual
Name
Institution
Telephone
Email
*Seconding Individual
Name
Institution
Email
Telephone


Please select your track and answer the questions for the track.

  • RESEARCHER/INVESTIGATOR TRACK
  • CLINICIAN/EDUCATOR TRACK

    • RESEARCHER/INVESTIGATOR TRACK

    Provide examples of intramural and/or extramural past and present grant funding, if applicable (evaluation value 1-3 points)::

    List up to 10 peer-reviewed publications (evaluation value 1-3 points):

    Provide the name, date, meeting venue, and presentation type (e.g., keynote, research platform or poster presentations, workshop, etc) of up to 5 regional or national presentations (evaluation value 1-3 points):

    List the title and dates of up to 5 former or current academic leadership roles you have held (evaluation value 1-3 points):

    Provide the name, function, years of service, and host organization of up to 3 academic committees or councils on which you've served (evaluation value 1-3 points):

    Provide the name and rank or level of training of up to 5 individuals whom you have mentored in a poster or platform presentation at a regional or national meeting, including SSCI (evaluation value 1-3 points):

    Have you been to the SSCI annual meeting within the last three years? (evaluation value 0 points):
    [VAR_MEMBERSHIP_PATH1_QUESTION7]

    CLINICIAN/EDUCATOR TRACK

    List the title and dates of up to 5 former or current academic leadership roles you have held (evaluation value 1-3 points):

    Provide the name, date, meeting venue, and presentation type (e.g., keynote, workshop, scholarly platform or poster presentation) of up to 10 regional or national presentations (evaluation value 1-3 points):

    List up to 5 peer-reviewed publications and/or curricular or other educational innovations and the educational course or training program in which the innovation was implemented (evaluation value 1-3 points):

    Provide the name, function, years of service, and host organization of up to 3 academic committees or councils on which you've served (evaluation value 1-3 points):

    List the name and awarding entity of up to 5 awards/recognitions you have received that involve education (i.e., for teaching or educational excellence) (evaluation value 1-3 points):

    Provide the name and rank or level of training of up to 5 individuals whom you have mentored in a poster or platform presentation at a regional or national meeting, including SSCI (evaluation value 1-3 points):

    Have you been to the SSCI annual meeting within the last three years? (evaluation value 0 points):
    [VAR_MEMBERSHIP_PATH2_QUESTION7]

Provide a statement of 500 words or less that explains why you are seeking Fellowship in the SSCI and how you intend to contribute to the organization:

Upload a copy of your current curriculum vitae (CV) as an Adobe PDF; note: the file must be a PDF to upload.

       

Contact The SSCI

Telephone: 205-648-8429 Cell: 205-566-6090

205-648-8429
205-566-6090

jkemp5@tulane.edu
Contact Form

Southern Society for Clinical Investigation
6359 Tribute Lane
Dora, AL 35062

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