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CDRH Medical Device Fellowship Program - Application Form

(See Paperwork Reduction Act Statement at the bottom of the form.)

Eligibility Criteria:

Candidates must be US citizens or permanent residents.
Students must be enrolled in an accredited U.S. college or university and have received at least 60 credit hours in undergraduate study.
Candidates must be free of conflict of interest.

Application Tips:

Please visit the MDFP website before completing this online application.
After submitting this form, you will be instructed to submit your updated curriculum vitae and letter of interest in CDRH in order to complete the application. Students must submit an academic transcript.
- Submit by email: mdfp@fda.hhs.gov
- Or mail to this address:
  Medical Device Fellowship Program (MDFP)
  Center for Devices and Radiological Health, FDA
  10903 New Hampshire Avenue
  WO 66 - 5456
  Silver Spring, MD 20993-0002
  301-796-6660

Application Deadlines

For Professionals:
- Applications are accpted year-round and should be submitted at least 3 months prior to the desired starting date.
For Students:
- Summer 2008 - submit applications between Oct. 1, 2007 and Feb. 1, 2008

* = required field

1. Personal Information

Name:
	(Dr/Mr/Ms/etc.)	*First	MI	*Last

*Date of Birth:			,
	Month	Day	Year

You can enter up to three degrees. Please list the highest degree as #1, the second highest as #2, and the third highest as #3.
Degree #1...	Degree: (MD, PhD, DVM, MS, etc) :
	Date Obtained :
	Name of Institution :

Degree #2...	Degree: (MD, PhD, DVM, MS, etc) :
	Date Obtained :
	Name of Institution :

Degree #3...	Degree: (MD, PhD, DVM, MS, etc) :
	Date Obtained :
	Name of Institution :

*Email Address :
Email Address : (Again, for verification)

*Permanent Address :

*City:
*State:		*Zip Code :

*Daytime Phone : xxx-xxx-xxxx
Evening Phone : xxx-xxx-xxxx

Veteran : No Yes

Citizenship Status : United States Citizen Permanent Resident

If permanent resident:	Country of Citizenship:
	Alien Registration No.:

Previous experience at FDA? : No Yes

Relative at FDA? : No Yes

If yes...	relative currently working at :
	relative's name :

2. Academic Information (Note: If not a student, please proceed to item #3)

School name :

Student's address at school:

City:
State:		Zip Code:

Student's phone at school :

Student's email :

Current education level :

Expected Date of Graduation :

Current cumulative GPA out of

Academic major(s) :
1:
2:

Position sought: Intern Co-op
Note: If seeking co-op position, student must be participating in a formal co-operative program at his/her school.

3. Employment Information (Note: If not currently employed, list most recent employment information.)

Company:

Position Title :

Start of Employment :		End of Employment : (if applicable)

Address:

City:
State:		Zip Code :

Phone :

Supervisor :

Supervisor Phone :

4. References

Please provide three references (other than current Supervisor).

Name 1:
(Dr/Mr/Ms/etc.)	*First	MI	*Last

*Title :

Phone : *or* Email :

Name 2:
(Dr/Mr/Ms/etc.)	*First	MI	*Last

*Title :

Phone : *or* Email :

Name 3:
(Dr/Mr/Ms/etc.)	*First	MI	*Last

*Title :

Phone : *or* Email :

5. Areas of Expertise / Academic Concentration

Please select all that apply:

Engineering:
		Biomedical	Chemical	Computer	Electrical
		Engineering Mechanics	Engineering Science	Human Factors	Materials Science
		Law	Mechanical	Quality / Manufacturing	Regulatory Issues
	Other Engineering or Sub-Specialty:

Medicine:
		Anesthesiology	Cardiology	Cardiothoracic Surgery	Dentistry
		Endocrinology	Gastroenterology	Immunology	Infection Control
		Law	Nephrology	Neurology	Neurosurgery
		Nursing	Obstetrics/Gynecology	Oncology	Ophthamology
		Oral surgery	Orthopaedics	Pediatrics	Plastic Surgery
		Psychiatry	Pulmonology	Radiation Therapy	Radiology
		Regulatory Issues	Urology
	Other Medicine or Sub-Specialty:

Mathematics and Science:
		Biology	Biotechnology / Biomolecular Studies	Chemistry	Computer Science
		Diabetology	Electrophysiology	Epidemiology	Human Factors
		Genetics	Law	Materials Science	Physics
		Psychology	Regulatory Issues	Statistics
	Other Mathematics & Science or Sub-Specialty:

6. Areas of Interest in CDRH

Please select up to three choices in the order of your preference (one from each column):

1st Choice		2nd Choice		3rd Choice
PREMARKET REVIEW...		PREMARKET REVIEW...		PREMARKET REVIEW...
	Anesthesiology		Anesthesiology		Anesthesiology
	Cardiovascular		Cardiovascular		Cardiovascular
	Dentistry		Dentistry		Dentistry
	Diagnostic Radiology		Diagnostic Radiology		Diagnostic Radiology
	Ear Nose and Throat		Ear Nose and Throat		Ear Nose and Throat
	Infection Control		Infection Control		Infection Control
	Gastroenterology and Renal		Gastroenterology and Renal		Gastroenterology and Renal
	General Surgery		General Surgery		General Surgery
	Human Factors		Human Factors		Human Factors
	In Vitro Diagnostics		In Vitro Diagnostics		In Vitro Diagnostics
	Law		Law		Law
	Neurology		Neurology		Neurology
	Neurosurgery		Neurosurgery		Neurosurgery
	Nephrology		Nephrology		Nephrology
	Obstetrics and Gynecology		Obstetrics and Gynecology		Obstetrics and Gynecology
	Ophthalmology		Ophthalmology		Ophthalmology
	Orthopaedics		Orthopaedics		Orthopaedics
	Plastic Surgery		Plastic Surgery		Plastic Surgery
	Radiation Therapy		Radiation Therapy		Radiation Therapy
	Regulatory Issues		Regulatory Issues		Regulatory Issues
	Respiratory		Respiratory		Respiratory
	Restorative Devices		Restorative Devices		Restorative Devices
	Urology		Urology		Urology
LABORATORY INVESTIGATION...		LABORATORY INVESTIGATION...		LABORATORY INVESTIGATION...
	Biological Risk Assessment		Biological Risk Assessment		Biological Risk Assessment
	Biotechnology and Biomolecular Studies		Biotechnology and Biomolecular Studies		Biotechnology and Biomolecular Studies
	Electrical, Electronics and Software Engineering		Electrical, Electronics and Software Engineering		Electrical, Electronics and Software Engineering
	Electromagnetics and Wireless Technologies		Electromagnetics and Wireless Technologies		Electromagnetics and Wireless Technologies
	Electrophysiology and Electrical Stimulation		Electrophysiology and Electrical Stimulation		Electrophysiology and Electrical Stimulation
	Fluid Dynamics and Ultrasonics		Fluid Dynamics and Ultrasonics		Fluid Dynamics and Ultrasonics
	Genomic and Genetic Devices		Genomic and Genetic Devices		Genomic and Genetic Devices
	Host Response: Tissue-Materials Interactions, Tissue-Device Interactions		Host Response: Tissue-Materials Interactions, Tissue-Device Interactions		Host Response: Tissue-Materials Interactions, Tissue-Device Interactions
	Materials Characterization and Polymer Degradation		Materials Characterization and Polymer Degradation		Materials Characterization and Polymer Degradation
	Mechanics of Materials and Diagnostics		Mechanics of Materials and Diagnostics		Mechanics of Materials and Diagnostics
	Optical Diagnostics and Therapeutics		Optical Diagnostics and Therapeutics		Optical Diagnostics and Therapeutics
	Optical Radiation Safety and Devices		Optical Radiation Safety and Devices		Optical Radiation Safety and Devices
	Radiation Bioeffects		Radiation Bioeffects		Radiation Bioeffects
	Radiological Health and Safety Program		Radiological Health and Safety Program		Radiological Health and Safety Program
POST-MARKET ACTIVITIES...		POST-MARKET ACTIVITIES...		POST-MARKET ACTIVITIES...
	Postmarket Surveillance		Postmarket Surveillance		Postmarket Surveillance
	Epidemiology		Epidemiology		Epidemiology
	Biostatistics		Biostatistics		Biostatistics
	Law		Law		Law
	Manufacturing Practices		Manufacturing Practices		Manufacturing Practices
	Regulatory Issues		Regulatory Issues		Regulatory Issues

7. Dates of Availability

Desired start date :

Desired length of appointment:

For Co-op Students:

Cancel and Return to MDFP Home Page

Paperwork Reduction Act Statement

The public reporting burden for this collection of information is estimated to average one hour per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to this address:

Department of Health and Human Services
Food and Drug Administration
5600 Fishers Lane, Room 14C-03
Rockville, MD 20857

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

FORM FDA 3608 (06/05)

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CDRH Medical Device Fellowship Program - Application Form