Program Director Questionnaire for 2024-2025 Fellowship Certification (VBA Fee Waiver)

You have been designated by an applicant as their Fellowship Program Director in reference to their application for SAGES Advanced GI MIS or Advanced GI MIS & Comprehensive Flexible Endoscopy Fellowship Certification.

The form below includes general questions regarding their fellowship experience as well as a brief attestation related to the videos they uploaded.

Program Director Name*

First Last

Program Director Email*

Fellowship Program Name/Institution*

Applicant Name

First Last

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.

Excellent	Very Good	Good	Fair	Poor

Patient 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.

Excellent	Very Good	Good	Fair	Poor

Practice-Based Learning And Improvement*

Practitioners are expected to be able to use scientific evidence and methods to investigate, evaluate, and improve patient care practices.

Excellent	Very Good	Good	Fair	Poor

Interpersonal 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 teams

Excellent	Very Good	Good	Fair	Poor

Professionalism*

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.

Excellent	Very Good	Good	Fair	Poor

Systems-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.

Excellent	Very Good	Good	Fair	Poor

Please 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

Successfully completed the Fellowship.*

Yes

Submitted a scholarly activity for consideration for a meeting or publication.*

Yes

Participated in at least one professional development activity, such as a meeting, postgraduate course or CME certified hands-on course.*

Yes

Had privileges to admit or treat patients modified, suspended, reduced or revoked?*

Yes

Uncertain

Been the subject of any disciplinary action by any licensing authority, health care facility or society?*

Yes

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

Uncertain

Been a defendant in a medical malpractice action?*

Yes

Uncertain

Been convicted of a felony?*

Yes

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

Uncertain

Please clarify all "Yes" answers here*

Certification of videos submitted for VBA Pilot:*

I certify that the videos submitted by my fellow to SAGES meet the following conditions:
• The fellow identified above 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 by my fellow meet the conditions described above.

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*