Form FDA 3608 FDA 3608 CDRH Medical Device Fellowship Program

Application for Participation in the Medical Device Fellowship Program; Form FDA 3608

Medical Device Fellowship Program (EEP, OCD, CDRH) CDRH Medical Device Fellowship Program - Application Form.htm

Application for Participation in the Medical Device Fellowship Program; Form FDA 3608

OMB: 0910-0551

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 CDRH Medical Device Fellowship Program - Application Form
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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 interest.

Application Tips:

  1. Please visit the MDFP website 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: [email protected]
    • 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 2011 - submit applications between Oct. 1, 2010 and Feb. 1, 2011

* = required field


1. Personal Information

Name:
 
         
*Date of Birth: ,
 
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 #2... :
  :
:

Degree #3... :
:
:

:
: (Again, for verification)

* :
 
:

: xxx-xxx-xxxx
:  xxx-xxx-xxxx

: No      Yes

: United States Citizen      Permanent Resident

    If permanent resident: :
  :

: No      Yes

:                   No      Yes

If yes... :
  :

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

:

   
 
:

:

:

:

:

:
1:
2:

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.)

:

:

:       : (if applicable)
 
     
   
 
:

:

:

:


4. References

Please provide three references (other than current Supervisor).

Name 1:

:

: *or* :


Name 2:

:

: *or* :


Name 3:

:

: *or*   :


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):

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

:

:

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
Office of Information Management
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 April 30, 2011.

FORM FDA 3608 (06/05)

    
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