Name_______________________________________________________________

Address_____________________________________________________________

____________________________________________________________________

City___________________________ State_________________

Zip______________

Telephone___________________Fax___________________E-Mail______________

Residency Program - Chief Year____________________

Year Completed 19_______


Specialty:

__ General Surgery (incl Oncology, Trauma, Transplantation)
__ Colon/Rectal Surgery	__ Pediatric Surgery
__ Neurological Surgery	__ Plastic Surgery
__ Obstetrics/Gynecology	__ Thoracic
__ Ophthalmic Surgery	__ Urologic Surgery
__ Orthopaedic Surgery	__ Vascular Surgery
__ Other (please specify in CAPS) __________________________

1o Board Certification (or equivalent):_______________________ DATE 19____

Additional Certification: ____________________ DATE 19____

Recertified: _ Yes Date: 19____ _ No

__________


If you are applying for verification based on education and training in US during residency or fellowship, please complete "Documentation of Structured US Educational Program During Residency."

All applicants should complete "Documentation of Clinical Experience."
__________

COURSE CONTENT:

• Didactic US Education (hours) ________ (Minimum 6) YES ___ NO ___
  • US Physics YES ___ NO ___
  • Instrumentation/Scanning Techniques YES ___ NO ___
  • Bioeffects of US/US Safety YES ___ NO ___
    
• Clinical Skills Training:
  • Trauma/Critical Care YES ___ NO ___
  • Breast YES ___ NO ___
  • Laparoscopic YES ___ NO ___
  • General Abdominal YES ___ NO ___
  • Intraoperative YES ___ NO ___
  • Vascular YES ___ NO ___
  • Endoluminal YES ___ NO ___
  • Head and Neck YES ___ NO ___
  • Pelvic YES ___ NO ___
  • Hepatobiliary YES ___ NO ___

I hereby certify that the above named individual has completed the described educational program and has performed and interpreted the recorded number of ultrasound images and ultrasound-guided procedures with outcomes assessed by a continuous quality improvement system.

_________________________________
Program Director (signature)

_________________________________
Program Director (printed)

__________

DOCUMENTATION OF POSTGRADUATE EXPERIENCE

List the hospitals at which you have current hospital privileges and at which ultrasound will be performed.

Hospital

_______________________________

_______________________________

_______________________________

Chief of Surgery (signature)

_______________________________

_______________________________

_______________________________

Statement 31

CESTE

Committees and Task Forces

Division of Education

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by the American College of Surgeons, Chicago, IL 60611-3211