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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 past and present grant funding, if applicable:

    List a representative selection (up to 10) of peer-reviewed publications along with the h-index if available:

    Provide the name and meeting venue of a representative selection (up to 5) of regional or national presentations:

    List the title and dates of a representative selection of former or current research-related leadership roles:

    Provide the name, function, and host organization of up to 3 research committees or councils on which you have served:

    Provide the name and rank or level of training of one individual who would consider you a mentor:

    CLINICIAN/EDUCATOR TRACK

    List the title and dates of a representative selection of former or current educational leadership roles:

    Provide the name and meeting venue of a representative selection (up to 5) of regional or national presentations:

    List a representative selection (up to 5) of publications and/or curricular or other educational innovations and the educational course or training program in which the innovation was implemented:

    Provide the name, function, and host organization of up to 3 educational committees or councils on which you have served:

    List the name and awarding entity of a representative selection (up to 5) of awards/recognitions you would like to highlight that involve education (i.e., for teaching or educational excellence):

    Provide the name and rank or level of training of one individual who would consider you a mentor:

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.

       
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The SSCI Thanks Its Sponsors

  • Elsevier sponsors The Southern Society for Clinical Investigation
  •