University of Pittsburgh School of Medicine
Department of Psychiatry
Application for Postgraduate
Forensic Psychiatry Fellowship
Western Psychiatric Institute and Clinic
NAME
SOCIAL SECURITY NO.
DATE OF BIRTH
Attach recent photograph
PRESENT ADDRESS
TELEPHONE: DAY
EVENING
EMAIL
PERMANENT ADDRESS
TELEPHONE: DAY
EVENING
EMAIL
CITIZENSHIP
NRMP NO.
Residencies Psychiatric
Hospital/Institution
Dates
Dept Chair/Training
Director
Electives/Awards
Dates
Dept Chair/Training Director
Electives/Awards
State (state licenses)
Type (certifications)
Year
Current
Residencies Other
Hospital/Institution
License/Certificate
State Licenses/Board Certificates
Medical education
Medical School(s)
City
State
Have you complete Steps 1, 2 and 3 for the Federation of State Medical Boards
From (mo/yr)
___ yes
___ no
Date of Medical School Graduation_______ Please have medical school transcript sent to:
Abhishek Jain, MD
Program Director
Forensic Psychiatry Fellowship
Western Psychiatric Institute and Clinic
3501 Forbes Avenue, 7th Floor
Pittsburgh, PA 15213
To (mo/yr)
Name:
[7/01] University of Pittsburgh School of Medicine - Psychiatry
Have you passed step 1,2,3,of the USMLE ___ yes
___ no
step 1 date_______
step 2 date________
step 3 date________
Undergraduate / Graduate / Postgraduate Education
School(s)
From (mo/yr)
To (mo/yr)
Major
Degree (if any)
Name
City
State
Name
City
State
Name
City
State
Service Obligations (National Health Service Corps, Armed Forces Scholarship, State Programs etc.)


I am not required to fulfill any service obligations
If Yes:
I am committed to fulfill the following service obligations:
 Yes
 No
Personal





Have you ever been the subject of disciplinary action by a hospital, state/professional board?
Has your medical license ever been revoked or suspended?
Have you ever been named in malpractice litigation?
Have you ever been convicted of a felony?
Have you ever been dismissed from college/medical school/residency for
behavioral/academic reasons?
 Yes
Yes
Yes
Yes




No
No
No
No
Yes  No
If the answer to any of the above is yes, please explain on a separate paper.
Interview
After your application is reviewed and you are to be invited for an interview, you will be contacted by the
WPIC Office of Residency Training (ORT).
Other
Please submit:
 three letters of recommendations; one must be from the chairman of the Department of
Psychiatry or from the residency training director of your residency.
 CV
 two samples reports
 a one page statement of intent describing your interest in forensic psychiatry including any
experience you have had; please include your goals and objectives for training
[7/01] University of Pittsburgh School of Medicine - Psychiatry
Signature of Applicant
Name:
Date