Advanced Resucitation Fellowship Program

Enrollment Application

First Name *

Last Name *

Phone *

Email *

Affiliated Organization *

Primary Areas of Specialty (Select all that apply)

Current PGY Level/ Fellowship Year

Estimated Date of Fellowship Completion

Experience & Clinical Exposure

Describe your current clinical exposure to trauma and hemorrhage control procedures (e.g., REBOA, massive transfusion protocol, resuscitative thoracotomy).

Why are you interested in participating in this Hemorrhage Control Fellows Program? What do you hope to gain?

Are you involved in resident or medical student education? Please describe your teaching experience.

Have you led or contributed to any quality improvement or research initiatives in trauma or resuscitation?

Are you interested in contributing to future protocol development, research, or educational outreach as part of this program?

Which Aortic Occlusion Catheter are you using at your institution *

Have you had hands-on experience with REBOA or other endovascular techniques during training?

Yes

Please upload all CV and letter of recommendation here *