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.
Your Name:

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* 1. Your Name:

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

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* 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.)

Main site (hospital):

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* 4. Main site (hospital):

Secondary Sites (hospital and/or ambulatory sites):

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

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

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

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

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

  Yes No
Poster presentations for local, state, or national meetings
Were any of the above submissions accepted?

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* 8. Were any of the above submissions accepted?

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

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

  Yes No
Oral presentations for local, state, or national meetings
Were any of the above submissions accepted?

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* 10. Were any of the above submissions accepted?

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

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

Please describe your teaching responsibilities:

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* 12. Please describe your teaching responsibilities:

What are your plans following completion of your fellowship?

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

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