Program Director Questionnaire for 2024-2025 Fellowship Certification – VBA Opportunity "*" indicates required fields You have been designated by an applicant as their Fellowship Program Director in reference to their application for one of the following SAGES Fellowship Certifications: Advanced GI MIS Advanced GI MIS & Comprehensive Flexible Endoscopy Fellowship (combined certificate) Advanced GI MIS + ACT Seal in Advanced Flexible Endoscopy The form below includes general questions regarding their fellowship experience as well as a brief attestation related to the videos they uploaded as part of their participation in the Society’s Video Based Assessment (VBA) pilot program.Program Director Name* First Last Program Director Email* Fellowship Program Name/Institution*Applicant Name* First Last Applying for Certification In*NOTE: Applicable payment has already been collected. 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* PROGRAM DIRECTOR ATTESTATION OF FELLOWS’ VIDEO SUBMISSION*• The fellow identified within this form served as the primary surgeon on the submitted procedures. • The fellowship program director or teaching faculty supervised the cases. • The program director, faculty or another qualified individual served as a passive assistant. • The assistant or supervising faculty did not provide any meaningful instruction, guidance, or intervention for the majority of the critical portions of the case related to the fundoplication (gastric and esophageal mobilization and wrap construction). I certify that the videos submitted to SAGES by my fellow meet the conditions described above. I further certify that I am the Fellowship Program Director and am familiar with the Fellow’s skills and practice. I certify I attest that my fellow has successfully completed the EPAs listed below.EPAs (Both EPAs 01 and 02 are required to receive the ACT Seal):* 01. Sedate and monitor patient for a flexible endoscopic procedure 02. Endoscopy in the patient with altered GI tract anatomy AND at least three EPAs from the list below (check all that apply):* 03. Evaluation and management the patient requiring advanced tissue resection/transection/ablation 04. Evaluation and management of obstructing or eroding GI tract processes 05. Evaluation and management of GI tract bleeding 06. Evaluation and management of partial and full thickness defects 07. 3rd space endoscopy/translumenal endoscopy 08. Evaluation and management of pancreatico-biliary diseases 09.Evaluation and management of patients needing complex endoscopic enteral access 10. Evaluation and endoscopic management of the patient with gastroesophageal reflux What is the best time to contact you by telephone?*Best Phone Number to Contact You:Your recommendation confirms that the applicant has: 1. Successfully completed your fellowship. 2. Has demonstrated the abilities and aptitude to perform the relevant procedures safely. 3. 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*