Download:
pdf |
pdfMedical Device Fellowship Program (EEP, OCD, CDRH) > CDRH Medical Device Fello... Page 1 of 4
Home About FDA Working at FDA Fellowship, Internship, Graduate, & Faculty Programs
About FDA
CDRH Medical Device Fellowship Program - Application Form
(See Paperwork Reduction Act Statement at the bottom of the form.)
Eligibility Criteria:
1. Candidates must be US citizens or permanent residents.
2. Students must be enrolled in an accredited U.S. college or university and have received at least 60 credit hours in undergraduate study.
3. Candidates must be free of conflict of interest1.
Application Tips:
1. Please visit the MDFP website2 before completing this online application.
2. 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 - G406
Silver Spring, MD 20993-0002
301-796-6660
Application Deadlines
For Professionals:
Applications are accepted year-round and should be submitted at least 3 months prior to the desired starting date.
For Students:
Summer 2014 - submit applications between Oct. 1, 2013 and Feb. 1, 2014
* = required field
1. Personal Information
Name:
(Dr/Mr/Ms/etc.)
*First
MI
*Last
,
1
*Date of Birth: January
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:
None
(MD, PhD, DVM, MS, etc) :
2012
Date Obtained : January
Name of Institution :
Degree #2...
Degree:
None
(MD, PhD, DVM, MS, etc) :
Date Obtained : January
2012
Name of Institution :
Degree #3...
Degree:
None
(MD, PhD, DVM, MS, etc) :
Date Obtained : January
2012
Name of Institution :
*Email Address :
Email Address :
(Again, for verification)
*Permanent Address :
*City:
*State:
*Zip Code :
*Daytime Phone :
Evening Phone :
Veteran :
No
xxx-xxx-xxxx
xxx-xxx-xxxx
Yes
Citizenship Status :
United States Citizen
Permanent Resident
If permanent resident:Country of Citizenship:
Alien Registration No.:
Previous experience at FDA? :
No
Relative at FDA? :
No
Yes
Yes
If yes... relative currently working at :
relative's name :
2. Academic Information (Note: If not a student, please proceed to item #3)
http://www.fda.gov/AboutFDA/WorkingatFDA/FellowshipInternshipGraduateFacultyProg... 7/31/2013
Medical Device Fellowship Program (EEP, OCD, CDRH) > CDRH Medical Device Fello... Page 2 of 4
School name :
Student's address at school:
City:
State:
Zip Code:
Student's phone at school :
Student's email :
Current education level : Pursuing Bachelors
Expected Date of Graduation : January
Current cumulative GPA
2012
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 :
January
2012
End of Employment : (if applicable)
(not applicable)
(na)
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 :
Name 2:
(Dr/Mr/Ms/etc.)
*Title :
Phone :
Name 3:
(Dr/Mr/Ms/etc.)
*Title :
Phone :
*or* Email :
*First
MI
*Last
MI
*Last
*or* Email :
*First
*or* Email :
5. Areas of Expertise / Academic Concentration
Please select all that apply:
Engineering:
Biomedical
Engineering Mechanics
Chemical
Engineering Science
Computer
Human Factors
Electrical
Materials Science
Medicine:
Anesthesiology
Endocrinology
Cardiology
Gastroenterology
Cardiothoracic Surgery
Immunology
Dentistry
Infection Control
Orthopaedics
Pulmonology
Pediatrics
Radiation Therapy
Plastic Surgery
Radiology
Law
Other Engineering or Sub-Specialty:
Law
Nursing
Oral surgery
Psychiatry
Regulatory Issues
Other Medicine or Sub-Specialty:
Mathematics and Science:
Biology
Diabetology
Genetics
Mechanical
Nephrology
Obstetrics/Gynecology
Urology
Biotechnology / Biomolecular
Studies
Electrophysiology
Law
Quality / Manufacturing
Neurology
Oncology
Regulatory Issues
Neurosurgery
Ophthamology
Chemistry
Computer Science
Epidemiology
Materials Science
Human Factors
Physics
http://www.fda.gov/AboutFDA/WorkingatFDA/FellowshipInternshipGraduateFacultyProg... 7/31/2013
Medical Device Fellowship Program (EEP, OCD, CDRH) > CDRH Medical Device Fello... Page 3 of 4
Psychology
Regulatory Issues
Other Mathematics & Science or Sub-Specialty:
Statistics
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
PREMARKET REVIEW...
PREMARKET REVIEW...
Anesthesiology
Anesthesiology
Cardiovascular
Cardiovascular
Dentistry
Dentistry
Diagnostic Radiology
Ear Nose and Throat
Diagnostic Radiology
Ear Nose and Throat
Infection Control
Gastroenterology and Renal
Infection Control
Gastroenterology and Renal
General Surgery
Human Factors
General Surgery
Human Factors
In Vitro Diagnostics
Law
In Vitro Diagnostics
Law
Neurology
Neurosurgery
Neurology
Neurosurgery
Nephrology
Obstetrics and Gynecology
Nephrology
Obstetrics and Gynecology
Ophthalmology
Orthopaedics
Ophthalmology
Orthopaedics
Plastic Surgery
Radiation Therapy
Plastic Surgery
Radiation Therapy
Regulatory Issues
Respiratory
Regulatory Issues
Respiratory
Restorative Devices
Urology
Restorative Devices
Urology
LABORATORY INVESTIGATION...
Biological Risk Assessment
LABORATORY INVESTIGATION...
Biological Risk Assessment
3rd Choice
PREMARKET REVIEW...
Anesthesiology
Cardiovascular
Dentistry
Diagnostic Radiology
Ear Nose and Throat
Infection Control
Gastroenterology and Renal
General Surgery
Human Factors
In Vitro Diagnostics
Law
Neurology
Neurosurgery
Nephrology
Obstetrics and Gynecology
Ophthalmology
Orthopaedics
Plastic Surgery
Radiation Therapy
Regulatory Issues
Respiratory
Restorative Devices
Urology
LABORATORY INVESTIGATION...
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
Genomic and Genetic Devices
Host Response: Tissue-Materials Interactions,
Tissue-Device Interactions
Materials Characterization and Polymer
Degradation
Mechanics of Materials and Diagnostics
Fluid Dynamics and Ultrasonics
Genomic and Genetic Devices
Host Response: Tissue-Materials Interactions,
Tissue-Device Interactions
Materials Characterization and Polymer
Degradation
Mechanics of Materials and Diagnostics
Fluid Dynamics and Ultrasonics
Genomic and Genetic Devices
Host Response: Tissue-Materials Interactions,
Tissue-Device Interactions
Materials Characterization and Polymer
Degradation
Mechanics of Materials and Diagnostics
Optical Diagnostics and Therapeutics
Optical Radiation Safety and Devices
Optical Diagnostics and Therapeutics
Optical Radiation Safety and Devices
Optical Diagnostics and Therapeutics
Optical Radiation Safety and Devices
Radiation Bioeffects
Radiological Health and Safety Program
Radiation Bioeffects
Radiological Health and Safety Program
Radiation Bioeffects
Radiological Health and Safety Program
POST-MARKET ACTIVITIES...
Postmarket Surveillance
POST-MARKET ACTIVITIES...
Postmarket Surveillance
POST-MARKET ACTIVITIES...
Postmarket Surveillance
Epidemiology
Biostatistics
Epidemiology
Biostatistics
Epidemiology
Biostatistics
Law
Manufacturing Practices
Law
Manufacturing Practices
Law
Manufacturing Practices
Regulatory Issues
Regulatory Issues
Regulatory Issues
7. Dates of Availability
Desired start date : January
1
2012
Desired length of appointment: Less Than 6 months
For Co-op Students: (Not Applicable)
Submit Form
Clear
Cancel and Return to MDFP Home Page3
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
Office of Information Management
http://www.fda.gov/AboutFDA/WorkingatFDA/FellowshipInternshipGraduateFacultyProg... 7/31/2013
Medical Device Fellowship Program (EEP, OCD, CDRH) > CDRH Medical Device Fello... Page 4 of 4
1350 Piccard Drive; Pi50 Rm 400B
Rockville, MD 20850
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. Information collected for the Medical Device Fellowship Program is approved under OMB Control No. 0190-0551 and expires March 31,
2014.
FORM FDA 3608 (06/05)
Page Last Updated: 04/15/2013
Note: If you need help accessing information in different file formats, see Instructions for Downloading Viewers and Players.
Accessibility Contact FDA Careers FDA Basics FOIA No Fear Act Site Map Transparency Website Policies
U.S. Food and Drug Administration
10903 New Hampshire Avenue
Silver Spring, MD 20993
Ph. 1-888-INFO-FDA (1-888-463-6332)
Email FDA
For Government For Press
Combination Products Advisory Committees Science & Research Regulatory Information Safety Emergency Preparedness International Programs
News & Events Training and Continuing Education Inspections/Compliance State & Local Officials Consumers Industry Health Professionals FDA
Archive
Links on this page:
1. /AboutFDA/WorkingatFDA/FellowshipInternshipGraduateFacultyPrograms/MedicalDeviceFellowshipProgramCDRH/ucm108129.htm
2. /AboutFDA/WorkingatFDA/FellowshipInternshipGraduateFacultyPrograms/MedicalDeviceFellowshipProgramCDRH/default.htm
3. /AboutFDA/WorkingatFDA/FellowshipInternshipGraduateFacultyPrograms/MedicalDeviceFellowshipProgramCDRH/default.htm
http://www.fda.gov/AboutFDA/WorkingatFDA/FellowshipInternshipGraduateFacultyProg... 7/31/2013
| File Type | application/pdf |
| File Title | http://www.fda.gov/AboutFDA/WorkingatFDA/FellowshipInternshipGr |
| Author | ACorbin |
| File Modified | 2014-01-23 |
| File Created | 2013-07-31 |