PEDIATRIC NEUROPSYCHOLOGY FELLOWSHIP
Application Checklist
The following checklist will help with ensuring you have a complete application.
You may include this checklist with the rest of your application.
Incomplete applications will not be considered after the deadline.
Enclosed/Attached for Application
Letter of interest
Curriculum Vitae
Two example pediatric neuropsychological reports
Copies of relevant publications (If applicable)
Application form (the remainder of this document)
The following information should be sent directly to the director of training from the respective
organizations and people
Official graduate school transcripts
Statement from graduate school clinical training director
Three letters of recommendation
PEDIATRIC NEUROPSYCHOLOGY FELLOWSHIP
Application Form
Applicant Information
Full Name
Citizenship
Canadian
USA
Other:
Phone number
E-Mail
Mailing address
APPCN Match Number
Doctoral Program
Degree type
Ph.D.
Psy.D.
Other:
University
Accreditation
CPA
APA
Other:
CPA
APA
Other:
None
Completion date (or anticipated date)
Dissertation title
Dissertation supervisor
Pre-Doctoral Internship
Internship institution
Accreditation
Rotations completed (indicate major or minor)
Primary internship supervisor(s)
Completion date (or anticipated date)
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None
Please note that while the following sections provide space for indicating an extensive depth and breadth of clinical
skills and experience, we do not expect that most applicants will have training and experience in all of these areas.
Assessment Experience – Pediatric (Ages 1-17)
Please indicate the number of assessments with each type of primary patient population in which you conducted
most of the testing and report writing. Do not count any cases in more than one patient category.
Number of Cases
None
1–5
6 – 10
11 – 20
> 20
Epilepsy (non-surgical)
Epilepsy Surgery
Traumatic Brain Injury
Stroke/Vascular/Hematology
Oncology/Neuro-Oncology
ADHD
Learning Disability
Autism
Psychiatric (e.g., Depression)
Other:
Assessment Experience – Adult (Ages 18+)
Please indicate the number of assessments with each type of primary patient population in which you conducted
most of the testing and report writing. Do not count any cases in more than one patient category.
Number of Cases
None
1–5
Epilepsy (non-surgical)
Epilepsy Surgery
Traumatic Brain Injury
Stroke/Vascular/Hematology
Oncology/Neuro-Oncology
ADHD
Learning Disability
Autism
Psychiatric (e.g., Depression)
Other:
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6 – 10
11 – 20
> 20
Test mastery
Please indicate your level of mastery with the following assessment instruments / techniques. ‘Fully proficient’
means you have been trained on the measure, have given it to at least 5 patients, and have interpreted the results.
Fully proficient
Some experience
No experience
WPPSI-IV
WISC-IV
WAIS-IV
RIAS/RIST
K-ABC-II
CMS
CVLT-C
CVLT-II
WMS-IV
RAVLT
RCFT
TOMAL-2
WRAML-2
CTMT
CVMT
WCST
NEPSY-II
D-KEFS
CPT-II/IVA/TOVA
WJ-III
WIAT-III
WRAT-4
PVTs (TOMM, MSVT, WMT)
Dichotic Listening
Language Mapping
Wada Test
Please list any other neuropsychological tests that you would consider ‘fully proficient’ (trained on it, administered
clinically at least five times, and interpreted the results).
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Please note that while the following sections provide space for indicating an extensive depth and breadth of skills and
experience, we do not expect that most applicants will have training and experience in all of these areas.
Research Skills
Please indicate your level of knowledge and experience with the following diagnostic imaging and analysis methods.
Extensive
Some
None
Structural MRI
fMRI
MRS
DTI
MEG
PET
EEG
Please indicate your level of knowledge and experience with the following software and data analysis methods.
Extensive
SPSS
SYSTAT
S+/R
M plus
SAS
Linear Regression
Logistic Regression
Multivariate Linear Analysis
Hierarchical / Mixed-Model
Factor Analysis
Power Analysis
Nonparametric Methods
Please list any other statistical or research experience/skills that you have.
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Some
None
References
A minimum of three references are required. Two references must come from (1) your graduate program and (2) your
pre-doctoral internship. These may be your primary supervisor and/or director of training from either setting. If you
are unable to list primary supervisors and/or director of training from your graduate program or internship as
references, please attach an explanation and list alternate references.
Graduate Program: supervisor or director of training
Name
Title
Name of Institution
Telephone
E-Mail
Address
Pre-doctoral internship: supervisor or director of training
Name
Title
Name of Institution
Telephone
E-Mail
Address
Other Reference
Name
Title
Name of Institution
Telephone
E-Mail
Address
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Other Reference
Name
Title
Name of Institution
Telephone
E-Mail
Address
Other Reference
Name
Title
Name of Institution
Telephone
E-Mail
Address
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