Application

First Name *

Middle Name *

Last Name *

Primary Degree *

Specialty

Address *

City *

State *

Zip *

Mobile Phone *

Home Phone

Email *

Are you a US Citizen or a Lawful Permanent Resident? *

Yes

If No, Visa Status

States of Licensure: (past and present)

Upload Files

Upload your CV

Files must be less than 5 MB.
Allowed file types: txt rtf pdf doc docx.

Letter of Interest

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Additional Documents

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Answers to the following questions are required for consideration for employment

Has your license to practice your profession in any jurisdiction ever been surrendered, limited, suspended or revoked? *

Yes

Have your privileges at any hospital been suspended, diminished, revoked or not renewed? *

Yes

Do you have any malpractice claims pending or have any malpractice claims ever been settled against you? *

Yes

Has a lawsuit or claim involving your care of a patient been settled or paid even if you were not specifically named as a party or defendant? *

Yes

Have you ever been debarred from receiving federal funding in research or investigated with regard to research activities? *

Yes

Have you ever been investigated or prosecuted for any Medicare or Medicaid fraud allegations? *

Yes

Additional info

If you answered yes to any of these questions, please furnish additional information in this text box. Material omissions or misrepresentations relating to the information requested above may result in withdrawal of any offer of employment or later termination of employment.

Voluntary Disclosures

Gender

Ethnicity

Race

I identify as one or more of the classifications of protected veterans

Disabled Veteran

Recently Separated Veteran

Active Duty Wartime or Campaign Badge Veteran

Armed Forces Service Medal Veteran

Voluntary Self-Identification of Veteran Status

If you believe you belong to any of the categories of protected veterans (Disabled Veteran, Recently Separated Veteran, Active Duty Wartime or Campaign Badge Veteran, or Armed Forces Service Medal Veteran), please check the appropriate box below. We request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

Protected Veteran

I am protected veteran

I am NOT a protected veteran

I choose not to answer this question

Voluntary Self-Identification of Disability

Individuals with disabilities who anticipate requiring assistance during the application process may contact the Office for Disability Management Services at 919-668-6213. TTY 919-668-1329

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Answering this question is voluntary, but we hope that you will choose to respond. Any answer you give will be kept private and will not be used against you in any way. Click here if you require additional information on how to answer this question.

Please check one of the boxes below

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DON'T HAVE A DISABILITY

I DON'T WISH TO ANSWER

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Duke is an Affirmative Action / Equal Opportunity Employer committed to providing employment opportunity without regard to an individual’s age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Signature of Applicant *

By typing my name on this form, I certify that all information is correct.

Date *

Year

Month

Day

Staffer Email *

How did you hear about this opening at Duke Health? *

Please list the specific person, journal, or website:

Job List

Leave this field blank

Position - Duke Radiology, Division Chief of Cardiothoracic Imaging, Durham

Voluntary Self-Identification of Veteran Status

Voluntary Self-Identification of Disability

Reasonable Accommodation Notice