JUREI Video Classroom Reviewer Application Form

We are updating the JUREI Video Classroom tape/DVD collection and need reviewers for the latest courses. If you are a USA-licensed physician or an ARDMS credentialed sonographer you can be a JUREI reviewer. If you are selected to be a reviewer we will send to you a lecture from one of the most recent courses here at JUREI. You will have 1 week to view the lecture, write simple test questions related to the material, and fill out a form for your comments. On receipt of your review we will send the next lecture in the series. You get to keep the lectures at no charge. To apply to be a JUREI reviewer, complete the form below and return. If you are selected to become a Reviewer we will email you with your acceptance notice and will schedule shipment of your first lecture for review.

Name: Address City Telephone number: e-mail address: Areas in which I am qualified to review JUREI Video Classroom lectures: Abdomen OB/GYN Vascular Musculoskeletal Echocardiography Breast Prostate Fetal Echo Pediatrics Interventional Other Physicians please complete the following: Degree: MD DO Other (specify) # years practicing Current Specialty Board Certification Reviewers must be a member of our Target Audience. Please check the appropriate box from the list below: I presently use ultrasound in my practice I do not presently use ultrasound and I would like to learn to use ultrasound in my practice. Sonographers please complete the following: Degree ARDMS Credentials held Specialty areas in which you currently perform exams on a regular basis: Total # years practicing ultrasound post graduation/training
I agree that in return for receiving one or more JUREI Video Classroom lectures on DVD, I will view the content of the lecture(s), write 5 test questions for each lecture and complete the reviewer form for each lecture. The above materials will be received by JUREI no later than 1 week (7 calendar days) after I receive the lectures on DVD. By signing below, I will be submitting my application to become a JUREI reviewer and further attest that the information on this application is true and accurate and I agree that I will not copy or distribute the JUREI lectures that I receive under the terms of this agreement. Signature: Date

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JUREI Video Classroom Reviewer Application Form

Mail the completed form to Reviewer Application Processing Jefferson Ultrasound Institute Thomas Jefferson University Hospital 132 S. 10th Street, Suite 780 Main Bldg Philadelphia, PA 19107-5244 Or e-mail the completed document as a Microsoft Word file or .pdf file to stephen.hample@mail.tju.edu or fax the form to 215-923-9452