2021 SAGES Fellowship Certification – Program Director Questionnaire Dear Program Director, You are designated by an applicant as the Fellowship Program Director in reference to his/her application for SAGES Fellowship Certification. If your fellow meets this criteria, please complete this survey at your earliest convenience. Kind regards, SAGES Resident and Fellow Training CommitteeProgram Director Name* First Last Program Director Email* Fellowship Program Name/Institution* Applicant Name Applying for Certification In Clinical/Medical Knowledge*Practitioners are expected to demonstrate knowledge of established and evolving biomedical, clinical and social sciences, and the application of their knowledge to patient care and the education of others.ExcellentVery GoodGoodFairPoorPatient Care*Practitioners are expected to provide patient care that is compassionate, appropriate and effective for the promotion of health, prevention of illness, treatment of disease, and care at the end of life.ExcellentVery GoodGoodFairPoorPractice-Based Learning And Improvement*Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.ExcellentVery GoodGoodFairPoorInterpersonal And Communication Skills*Practitioners are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teamsExcellentVery GoodGoodFairPoorProfessionalism*Practitioners are expected to demonstrate behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity and a responsible attitude toward their patients, their profession, and society. The Joint Commission considers diversity to include race, culture, gender, religion, ethnic background, sexual preference, language, mental capacity and physical disability.ExcellentVery GoodGoodFairPoorSystems-Based Practice*Practitioners are expected to demonstrate both an understanding of the contexts and systems in which health care is provided, and the ability to apply this knowledge to improve and optimize health care. ExcellentVery GoodGoodFairPoorPlease feel free to add other comments. To the best of your knowledge, has the applicant:Accurately documented his/her cases, and level of involvement?* Yes No Successfully completed the Fellowship.* Yes No Submitted a scholarly activity for consideration for a meeting or publication.* Yes No Participated in at least one professional development activity, such as a meeting, postgraduate course or CME certified hands-on course.* Yes No Had privileges to admit or treat patients modified, suspended, reduced or revoked?* Yes No Uncertain Been the subject of any disciplinary action by any licensing authority, health care facility or society?* Yes No Uncertain Engaged in any alcohol, chemical or drug abuse/ dependency that affects the practitioner’s ability to perform safely the essential functions of the position applied for?* Yes No Uncertain Been a defendant in a medical malpractice action?* Yes No Uncertain Been convicted of a felony?* Yes No Uncertain Had a physical or mental health condition that affects or is reasonably likely to affect his/her ability to perform professional or medical staff duties?* Yes No Uncertain Please clarify all "Yes" answers here* What is the best time to contact you by telephone?* Best Phone Number to Contact You:Your recommendation confirms that the applicant has:* Successfully completed your fellowship on August 1, 2021 Has demonstrated the abilities and aptitude to perform the relevant procedures safely Has demonstrated appropriate moral, ethical, and professional behavior I, the Fellowship Program Director* Recommend Applicant for SAGES Fellowship Certification Recommend Applicant with Reservation Do Not Recommend Reservations*