1. General Information

The survey results are collated and shared only with the Fellowship Council Accreditation Committee. If a problem is identified, the program may be provided with general details in order to address the issue.

* 1. Your Name:

* 3. Cell Number (this is optional and allows FC Accreditation Committee members to contact you should they have additional questions during the accreditation review process.)

* 4. Main site (hospital):

* 5. Secondary Sites (hospital and/or ambulatory sites):

* 6. What percentage of time do you typically spend in the following activities (to equal 100%)?

* 7. Have you submitted or prepared any of the following during your fellowship?

  Yes No
Poster presentations for local, state, or national meetings

* 8. Were any of the above submissions accepted?

* 9. Have you submitted or prepared any of the following during your fellowship?

  Yes No
Oral presentations for local, state, or national meetings

* 10. Were any of the above submissions accepted?

* 11. If you have not submitted any posters/oral presentations to any meeting during your fellowship time, please describe your current scholarly activity:

* 12. Please describe your teaching responsibilities:

* 13. What are your plans following completion of your fellowship?

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