Application Form  for Post Doctoral Fellowship Program in Movement Disorders

Name of the Institute *
Course Director's Name for the Movement Disorders Fellowship Program *
Name, email id, phone number of the contact person *
Qualifying criteria for fellows *
Number of Movement Disorders trained faculty *
Name of faculty 1. *
Degree of the faculty *
Present Designation of the faculty *
Fellowship duration of the faculty (if fellowship in Movement Disorders done)
Institute from where fellowship obtained  (if fellowship in Movement Disorders done)
Post fellowship experience (if fellowship in Movement Disorders done)
If not fellowship trained, number of years of experience and focused work in Movement Disorders  
Name of faculty 2. 
Degree of the faculty
Present Designation of the faculty
Fellowship duration of the faculty (if fellowship in Movement Disorders done)
Institute from where fellowship obtained  (if fellowship in Movement Disorders done)
Post fellowship experience (if fellowship in Movement Disorders done)
If not fellowship trained, number of years of experience and focused work in Movement Disorders  
Name of faculty 3.
Degree of the faculty
Present Designation of the faculty
Fellowship duration of the faculty (if fellowship in Movement Disorders done)
Institute from where fellowship obtained  (if fellowship in Movement Disorders done)
Post fellowship experience (if fellowship in Movement Disorders done)
If not fellowship trained, number of years of experience and focused work in Movement Disorders  
Name of faculty 4. 
Degree of the faculty
Present Designation of the faculty
Fellowship duration of the faculty (if fellowship in Movement Disorders done)
Institute from where fellowship obtained  (if fellowship in Movement Disorders done)
Post fellowship experience (if fellowship in Movement Disorders done)
If not fellowship trained, number of years of experience and focused work in Movement Disorders  
Name of faculty 5.
Degree of the faculty
Present Designation of the faculty
Fellowship duration of the faculty (if fellowship in Movement Disorders done)
Institute from where fellowship obtained  (if fellowship in Movement Disorders done)
Post fellowship experience (if fellowship in Movement Disorders done)
If not fellowship trained, number of years of experience and focused work in Movement Disorders  
Proposed duration of the Program*
Full-fledged Neurology Department*
Number of weekly Movement Disorder Clinic *
Number of BOTOX Movement Disorder Clinic per year *
Number of Deep Brain Stimulation (DBS) surgery per year *
Will the fellow get the opportunity to be involved in DBS surgery for Movement Disorders*
Will the fellow be exposed to Infusion therapy (like Apomorphine)*
Number of Movement Disorders Video Sessions per month*
Number of Monthly Bedside Case discussions* 
Mention in brief about the opportunities for the fellows to be part of Movement Disorders Research Projects*
Mention in brief about the opportunities for the fellows to be part of the Movement Disorders Clinical Trials*
Please mention whether the fellows will be trained in the following: *

N.B :
At the end of the fellowship, the program director will be willing to give undertaking that the fellow has been appropriately trained as per the criterion mentioned in the Annexure