FORM - SUFU Visiting Professorship

FORM - SUFU Visiting Professorship

This application will need to be completed by the Program Director or Chairman.

The decision as to which programs will be selected for the SUFU Visiting Professorship will be made by members of the SUFU Executive Committee. That decision will be made on the basis of several factors, including presumed educational need, current exposure of trainees to FPMRS, as well as other aspects of the program applying.

Name*

(Last, First)

Contact Email*

Name of Institution*

Program Director*

Chairman Name*

Host City*

(City, State)

Number of Residents per year*

Number of Current FPMRS Faculty*

(ACGME Accredited)

Number of Faculty performs slings*

Performs on a regular basis (Non-ACGME Accredited)

Number of Faculty performs prolapsed repairs*

Performs on a regular basis (Non-ACGME Accredited)

# of Residents pursued FPMRS fellowship training*

Within the last 5 years

Rating for seeking an FPMRS trained physician*

Likelihood of seeking an FPMRS trained physician at your institution in the next 5 years. Please answer on scale of 1 to 5.

1 = NO and 5= Absolutely

Please indicate your preferred dates for the visit.

List in order of preference from most to least desired.

Date 1*

Date 2*

Date 3*

Send me a copy of my responses

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