ACS Program for Accredited Education Institutes

Thank you for your interest in surveying for the ACS-AEI Program! Please tell us a little bit about yourself and we will follow-up with next steps.

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* 1. Title, First and Last Name, and Credentials:

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* 2. Please enter the name of the Institution where you are currently employed or have an affiliation.

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* 3. Institution Address:

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* 4. Cell Phone Number:

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* 6. Home Address:

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* 7. Are you a Fellow of the American College of Surgeons?

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* 8. Are you an actively practicing (treating, teaching or administrative role) surgeon who specializes in the development of simulation-based surgical education and training?

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* 9. Are you employed or affiliated with an ACS accredited education institute (AEI)?

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* 10. Please use the space below to describe your responsibilities at your Institution.

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* 11. Please indicate below any languages you speak other than English and level of proficiency:

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* 12. Upload your current Curriculum Vitae (CV).

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* 13. Upload your bio.

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* 14. Upload your statement of interest in becoming a surveyor for the ACS Program for Accreditation of Education Institutes.

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* 15. Upload two recommendations from peers familiar with your experience working for a Surgical Education/ Skills Center.

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