SAGES IPC APPLICATION RATING SCALE
BASIC ENDOSCOPY COURSE
To be completed by selected application reviewers
Conflict of Interest
The following guidelines have been reviewed and approved by the SAGES Board and SAGES Global Affairs Committee.
It is the personal responsibility of the applicant and the reviewer to identify any possible conflict of interest situation that may impact the review of the application and/or the actual sustainability and/or continuity of a SAGES International Proctoring Course (IPC). The SAGES Global Affairs Committee Chair and/or Co-chair may also determine that a situation involves a conflict of interest and require that a potential reviewer or applicant not be involved or be withdrawn from the process.
There are several bases for a conflict of interest:
For the reviewer: Employment, direct financial benefit, personal relationships, professional relationships or other interests. If applicable, any one condition may serve to disqualify a reviewer from participating in the review of an application or proposal. A conflict of interest may be real or apparent.
For the applicant: Direct -personal financial benefit vs. benefit of the general- public. This condition may serve to disqualify an application form or proposal. A conflict of interest may be real or apparent.
GRANT EVALUATION CRITERIA & RATING SCALE
For the criteria identified, please outline strengths and weaknesses of the site. Detail, in writing, (preferably typed) your rationale for scoring the criterion. Assign each criterion a score between 1 and 5, with 1 being the lowest (unacceptable) and 5 being the highest (outstanding).
Specific concerns (additional letters and comments to numerical score):
Individual financial or medical practice conflicts of interest (COI): Ownership in private clinics, “black money” payments for services, local/regional distribution of medical supplies, etc.)
- Personal safety concerns (PS): Local conflict, kidnappings, crime
- Staffing concerns (SC): Hospital staffed by foreign surgeons, high surgeon turnover, “visiting” or itinerant surgeons
- Catchment area of local hospital
- Capability of maintenance of equipment and instrumentation
| Score 1-5 | |
| 1. Clinical Need | |
| 2. Hospital Infrastructure | |
| 3. Surgical Equipment | |
| 4. Admin & Political Support | |
| 5. Training and Sustainability | |
| 6. Self sufficiency |
Specific Comments (this section will be included in the letter to the applicant/institution):
SAGES IPC RATING GUIDELINES
To be completed by selected application reviewers
Reviewers: When considering your score, please see below chart for scoring guidelines. Assign each criterion a score between 1 and 5, with 1 being the lowest (unacceptable) and 5 being the highest (outstanding).
Please use this link if the survey below will not display: