AHNS Fellowship Program Evaluation Form

This form is to be completed by the graduating fellow. This is a prerequisite to receiving your Certificate of Completion, and this information will be kept strictly confidential.

Fellowship Program Evaluation

Graduating Fellow's Name
First Middle Last
Name of Program*
Fellowship Start Date*
MM
DD
YYYY
Fellowship End Date*
MM
DD
YYYY
PG Level Prior to Fellowship
ABMS Specialty
Intent in Pursuing this Fellowship*
- Research Experience
- Additional Clinical Experience
- Both
Post Fellowship Plans
- Private Practice
- Medical School Appointment
- Cancer Center Appointment
- Combination of the Above
- Undecided

Program General Survey*

	Not Applicable	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree
The program is well-rounded
Patient material is adequate in numbers
Patient material is mixed and diversified
Curriculum is approprirate
Conferences and didactic presentations are appropriate
Instruction on decision-making is adequate
Operating room experience is adequate
Availability of staff is adequate/sufficient in number
Supervision by faculty is enough
There is enough freedom for independent clinical decision-making
Clinical research exposure is available
Basic science instruction (theoretical, classroom) is adequate
Basic science training is appropriate
Overall, this is a good training program in head & neck oncologic surgery

Comments

The program allows for development of:

	Not Applicable	strongly Agree	Agree	Undecided	Disagree	Strongly Disagree
Basic Science Research Training
Oncological judgment
Surgical judgment
Teaching
Scholarship and academics
A sound head & neck oncologic surgeon

Comments

Your Program Director:

	Not Applicable	Strongly Agree	Agree	Undecided	Disagree	Strongly Disagree
is committed to excellent patient care
participates actively to trainee (fellow/resident) education
is available for consultation
gives positive feedback on performance at regular intervals
mentors/supervises the trainee in scholastic pursuits

Your program Director establishes effective working relationships with:
Not Applicable Strongly Agree Agree Undecided Disagree Strongly Disagree
Fellows/Residents
Nurses
Physician extenders
Other colleagues
Comments
State your greatest satisfaction with your fellowship:
State your greatest dissatisfaction with your fellowship;
Suggestions for Improvement

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AHNS Fellowship Program Evaluation Form

Fellowship Program Evaluation

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Fellowship Program Evaluation

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