DRAFT-SFFC 1Start Application2Program Director Information3Program Accreditation4Program Curriculum and Funding5Scholary Activities6Case Load Charts7File Uploads8Payment Information9Preview Application HiddenUser*aabbas@ochsner.orgaagumbs@gmail.comaarias@stanford.eduabarkan@winthrop.orgabaskara24@yahoo.co.ukAbenezer Mekonnen Tesemaacooper1@mdanderson.orgAdam RosenstockAdam.beall12@gmail.comAdnan.Alseidi@vmmc.orgAdominguez@aagl.orgahm_atia@hotmail.comAhmed Mahmoud AbdelrafeeAhmed Mohamed OsmanAhmet DemirAhrorbek Nematovich AdashalievAjensen@chla.usc.eduakanala@partners.orgakastenm@mcw.eduAkshay Pratap ChauhanAkshay Pratap ChauhanAlexandra Monique Sanchezalexchart@gmail.comAlfredo CarbonellAli Tavakkolialidor1@jhmi.edualireza_alam@yahoo.comAllison MossAllison Steinalp2014@med.cornell.edualplank@geisinger.eduAmal Hamad Alkhalafamine2505@hotmail.comamir.bastawrous@gmail.comamir.bastawrous@swedish.orgammarnuss@yahoo.comammorgan@geisinger.eduamr_abdellateef@yahoo.comamy lynn banks-venegoniAndrew WassefAndrew Wheelerandrewfarmer@usf.eduAngie KingstonAnna Wickanne.m.cahill@lahey.organne.sass@rsfh.comanup_14k@yahoo.comAristidis Konstantinos Ioannidisarthur.vieira@ymail.comarzaputra@gmail.comasemghasoup@yahoo.comAshley MixsonAshley Pellegriniaurora.pryor@duke.eduaurora.pryor@stonybrookmedicine.eduaxf266@case.edubansalnitinkumar@gmail.combarlowmsc@hotmail.combduran@mednet.ucla.edubellowscharles3@gmail.comBen Bitemanbennetv@mail.amc.edubernie.mudreski@roswellpark.orgberry037@stanford.edubeth.klausen@roswellpark.orgBethany Jo BrownBgardner@fresno.ucsf.edubjdunkin@houstonmethodist.orgblinman@email.chop.edubmrad@ualberta.caBobbie Corwinbowers.steven@mayo.eduBrandon WilliamsBrian Kiplagat MisoiBrian TolmanBrianne Leigh NickelBrittany HendersonBrittney N richmondBruntm@wustl.eduBryan Hallbs@virginia.edubsandler@ucsd.edubtjmd@skydsl.com.phbtmoore@saint-lukes.orgbtravislee@hotmail.combülent koyunburhop@surgery.wisc.eduburt1985@revenueads.netbvisser@stanford.educandace.newby@hhsys.orgCarli Timmermancarlospirelamed@gmail.comcarlyn.mathers@stonybrook.eduCarolyn Campeauxcatalfaf@upstate.educathy.betzer@providence.orgcathy.buckley@louisville.educbrathwaite@winthrop.orgccm6b@virginia.educfs@ucsd.educgalvani@surgery.arizona.educha9043@nyp.orgchandb@ccf.orgChaoquan Kevin Hucharles.scoggins@louisville.eduChasity M Adamschavinkd@musc.eduCheryl Alementichris.tzarnas@tuhs.temple.eduChristine Regan CareyChristopher DuCoinChristy Dunstcindy.c@kendrickcenter.comclairehoelscher@yahoo.comclary001@mc.duke.educlxia@houstonmethodist.orgcmichalik@kaleidahealth.orgcocoehl@gmail.comcoefire1@memorialhealth.comColleen AggiColleen Elkinscolleen@surgicalfellowships.orgcontivm@upmc.eduCooneyr@upstate.educorningc@uic.educpgordon@partners.orgcramerm1@ail.amc.educramerm1@mail.amc.educsarmstrong1@me.comCurtis Edward Bowercvesfel@uw.educwargo@plasticsurgery.orgcwestcot@wfubmc.eduCydney Herringcynthia.crump@franciscanalliance.orgdaf2028@med.cornell.edudana.marcus@jefferson.edudana@summahealth.orgdaneisenberg@stanford.eduDaniel de Freitas Soaresdaniel.herron@mountsinai.orgDanielle Leblangdarmstrong@gcrsa.comDavid Solomon Walshdavid.chen@fccc.edudavid.podkameni@bannerhealth.comDdiazcal@gmail.comddwater4life@gmail.comDEBORA BRASCIADeisens1@hfhs.orgdenise.gwinn@swedish.orgdfeldman@sbhcs.comDiana Ninodiann.carreker@inova.orgdicamach@montefiore.orgDiego Mauricio Avella Patinodiparreno@gmail.comdirouvarlen ramasawmydjuraev_tma@mail.rudkellermd@houstoncolon.comdm2933@columbia.edudmckenna@iupui.edudmitry.nepomnayshy@lahey.orgdmorvant@drleggett.comdnita@uic.edudoctorimranjaved@yahoo.comdonald.hess@bmc.orgdonnab@georgiahealth.edudougewingmd@gmail.comdporzio@stanford.eduDr .Peter M Georgedr_harivadan@yahoo.comDr_hdhy@hotmail.co.ukdr_jalberto_glezd@hotmail.comdr.arambula@gmail.comdr.naifalenazi@gmail.comDr.neha.chauhan@gmail.comdr.rachnabajaj@gmail.comdradarsh008@gmail.comdrattner@partners.orgdrbat888@hotmail.comdrdggohil@yahoo.comdrehabobgyngh@yahoo.comdrgrsmrn@gmail.comdrhaqq@gmail.comdrharishe@gmail.comdrimd1@aol.comdrisucci@gmail.comdrjunedsn@gmail.comdrk_goren@hotmail.comdrkapileshwer@gmail.comdrkiranmahadevappa@gmail.comdrprakashjain@gmail.comdrpriyankabatra@yahoo.comdrravikanojia@yahoo.comdrsahilsaroj@gmail.comdrsahu2k5@gmail.comdrselviradhika@yahoo.comdrstevemyers@gmail.comdrujjalghosh@yahoo.comdrvahidattar@gmail.comdsawyer@lhs.orgdselzer@iupui.edudsmith895@hotmail.comdsolomonjrmd@gmail.comdubeyanurag100@gmail.comdunya.moghul@fmic.org.afe_sigurdson@fccc.edueakkary@akkarysc.comeastsidesurgical@aol.comeasyshan@gmail.comEd Rosadoeduardo.parradavila.md@flhosp.orgedutson@mednet.ucla.edueestape@southmiamigog.comehaasmd@houstoncolon.comekimchi@psu.eduelin2@emory.eduEllen McCaffreyelukacz@ucsd.eduEmily Licenceenestved@ohsu.eduEric J DeMariaEric KwakyeEric SheuEric.Monnet@ColoState.EDUerik.b.wilson@uth.tmc.eduErin Griffinernest.rosato@jefferson.eduErnesto CatalasanErrowlAgele@tesiov.infoerthen@magasindubio.comeschomd@gmail.comesherrod@gcrsa.cometkimchi@yahoo.cometzioni.david@mayo.eduEvelyn Goteraf.rea@insightbb.comFabian McCartney JohnstonFahad Mohammed AlharbiFaisal Saber Abdulfattahfcaliend@nshs.edufeinberg@bcm.eduFelicia Ann Brownfelipevillalobos04@yahoo.comFrancisco Quinterosfranklin@texasendosurgery.comFred BrodyGabrielle GrubmanGACRS@aol.comgantanavicius@amh.orggellerda@upmc.eduGenie.Kruszynsky@ololrmc.comgeorgewilliamsmd@bellsouth.netGhusn Al Sideirigmancini@mc.utmck.edugonzalez@vrgmd.comgopalroy00@gmail.comgprasannabk@gmail.comGraham Cribbingreenbergj@surgery.wisc.edugreg.stiegmann@ucdenver.edugreggs@email.chop.eduguilherme.campos@vcuhealth.orgHabil Garivanihadl0052@umn.eduhartman.carlos@gmail.comhdbear@vcu.eduHeather Ann LorenzonHeather Kleinginnaheather.steinberg@bmc.orgHillary Wagenerhiran.fernando@bmc.orghlujan15@me.comholtond2@ccf.orghwalker3@ghs.orgi_zhivkov@abv.bgiannuccis@mlhs.orgigeorge@aahs.orgigeorge@smail.umaryland.eduIman GhaderiIntezar Ahmedisaac-samuel@uiowa.eduj2pete@mindspring.comJaclyn BuffingtonJaclyn.Stransky@UHhospitals.orgJacqueline McKenzie GlynnJaime Cudmorejalladfadi@hotmail.comjames.mcginty@mountsinai.orgjanet.adeletti@baystatehealth.orgjasonJason Levinejeffrey marksjennifer.cooper2@ahss.orgjennifer.raeke@inova.orgjenny_speranza@urmc.rochester.edujesksoito@mail.rujesse E morganJessica Afrose ZamanJewel CastleJibran Abbasyjkim7@tuftsmedicalcenter.orgjlberistain@yahoo.comJmanchio@gmail.orgjmarcet@health.usf.edujmartinez4@med.miami.edujmrockwe@uci.edujoanlmonaco@aol.comjoelkashou@gmail.comjoharvey@chpnet.orgJohn KellyJohn Rodriguezjohn_gaudieri@urmc.rochester.edujohn_guadieri@urmc.rochester.edujohn.harvey@chpnet.orgjohn.romanelli@bhs.orgJohnnie G. Collinsjohnson1@ccf.orgjohnstpe@njms.rutgers.eduJonathan Carterjonathan.carter@ucsfmedctr.orgJorge AutranJorge Enrique Marcetjose Antonio changjpark18@aol.comjpdeep@hotmail.comjrjoseph@ono.comjteixeira@chpnet.orgjunpaulcastolomd@yahoo.comJussuf Thomas Kaifijwallace@mcw.edujwalls@partners.orgKaren A NobleKarin WynnKarun SinglaKassaw Demilie AlemuKassem.shmaissany@ieo.itKatayun.irani@gmail.comKate Neckermannkathleen_caton@ssmhc.comkatmunoz@uci.eduKaty.McCormick@virginiamason.orgkaulmd@hotmail.comkay.s.alexander@vanderbilt.edukdugan@bidmc.harvard.eduKeith Boonekeith.andony@albertahealthservices.cakeith.zuccala@danhosp.orgkelle.scott@uth.tmc.eduKelly Stambergerkelly.rood@osumc.eduKendra ArmijoKenneth Chavinkeoughj@ccf.orgkevin_wolfe@nymc.edukfir.bendavid@surgery.ufl.edukgibbs@siuh.edukhaled_sah@hotmail.comkhorgami@gmail.comkimhj@med.unc.edukimt@upstate.edukjk_kunwar@hotmail.comklamond@smail.umaryland.edukorsro@valleyhealth.comKrasimira KALINOVA ATANASOVAKristen Skileskscharf@llu.edukstaveleyocarroll@hmc.psu.edukurt.roberts@yale.edukusuancod@cshs.orgkzahner@partners.orgl.harrison@valleyhealth.comLaila RashidiLamin Jaitehlance_porter@urmc.rochester.eduLarry Eli Gellmanlauren.moore@swedish.orgLaurent BierthoLaurie Woldmanlaurie@asbp.orgLawrence Koli KiokoLAYCOCK@HITCHCOCK.ORGlcabana@lifespan.orgleena.khaitan@uhhospitals.orgLeon Katzliane.feldman@mcgill.calidor@surgery.wisc.eduLinda MoralesLinda SchultzLinda SchultzLinda SchultzLinda Schultzlinda@bscmanage.comLindsay JacobyLindsey Kilgorelisa.bailey@utsouthwestern.edulisa.yeater@osumc.edulmorrison@aahs.orgLohrasb SayadiLois EhrlichLong R JiaoLori Ann BardonLori Joneslori_bush-siracusa@urmc.rochester.edulori.bianchi@bannerhealth.comLoryn DagerLou Franchinalovaske@upmc.edulowl.lewis@gmail.comlpompey@peachtreebariatrics.comlporitz@psu.edulyn.glenn@providence.orglynn.mccarthy@lahey.orgmaabby01@louisville.eduMaggie.Hamblen@erlanger.orgmaher.elchaar@sluhn.orgmanwaringm@ecu.eduMarcie Wienermarcoale14@hotmail.comMargaret Brown-DeanMarilyn RutkowskiMark Kligmanmark.roh@orlandohealth.commarond@ccf.orgmartinelizabeth1@yahoo.comMary Aganemary@dryadegar4life.commasonb@wusm.wustl.edumasoudpour@yahoo.commatraca.larasa@aol.comMatthew A Brownmatthew.hartwig@duke.edumdwyc2@yahoo.commeaghandaley@hotmail.commedicine_just@yahoo.comMegan WohlmanMelanie CameroMelanie Winfieldmelinda.hawkins@swedish.orgMelissa KumernitskyMelissa SullivanMelkamu Kibret Nidawmemcneil@bidmc.harvard.edumenkej@wudosis.wustl.edumeredithk@surgery.wisc.edumfairgri@stjosham.on.camhawn@uab.eduMichael DriggsMichael W Cookmichael.nussbaum@jax.ufl.edumichboettcher@gmail.commichelle.amabile@carolinas.orgmichelle.dewing@hotmail.commiguel.burch@cshs.orgmike.holzman@vanderbilt.edumingjuanxu68@yahoo.comMisty Pittmanmisurgery@fresno.ucsf.edumitoer70@gmail.commiuzcategui@yahoo.commkeener@aahs.orgmm2hx@virginia.edummaish@mednet.ucla.edummarohn1@jhmi.edumnaidu@srhs.orgmoralesl@cshs.orgmorton@stanford.edumpatti@surgery.bsd.uchicago.edumrali@ucdavis.edumralwan@hotmail.commschwei7@jhmi.edumstamos@uci.edumtbecker@partners.orgmuhammad.jawad@orlandohealth.commuhaned.farah@yahoo.commuraliikrishn@gmail.commurthy.kusuma@rediffmail.commzajawad@yahoo.commzeiger@jhmi.eduNancy Alice GervasioNathan James SmithNathaniel Pihancordova@stanford.edundelacruz@med.miami.eduNicholas Alexander La GammaNicole Barberionievesperpetuas@hotmail.comnisreenma@pcom.edunitein@gmail.comNJoiner@CRCOrlando.comnjyijun@163.comnoor.totah.91@gmail.comnzyromsk@iupui.eduoienx003@umn.eduOlga.Mateo-Rodriguez@wmchealth.orgOliver Nicholas McLarenOphelia Ashton Harknessorloffs@ohsu.eduOrwa Musa Abusabhapamfandrich@gmail.compatelmanthan.5@gmail.competer-nau@uiowa.eduphansen@orclinic.comPhillipe Abreupkarstetter@hmc.psu.edupkatsaronis@gmail.comPrakash R Paragiprofdan77@gmail.compseverson@cuyunamed.orgpsomasun@chartercare.orgRalph.Aye@Swedish.orgRAPHAEL FERREIRA DE MORAES FORJAZRashida Sanchezrbleday@partners.orgreardonp@texmist.comrevanthgangasani@gmail.comrfakhtar@gmail.comrgerding@iupui.eduRichard Kirk Englehardtrichard.barg@ucsfmedctr.orgRicky NagelRita Chambersrminter@umich.eduro255sibsagar@yahoo.co.inrobert.martin@louisville.eduRoby TESTrodney.mardirosian@cshs.orgrosenberge@cshs.orgrpressley@aahs.orgRshemin@mednet.ucla.edursstut03@louisville.eduRyan C Fieldssadashivpatil12@gmail.comsagesweb@sages.orgsaleem.noormohamed@gmail.comsalifu wada odaudusalome.r.roe@uth.tmc.edusamantha.kaiser@providence.orgSameer Mukundkumar PandyaSamer SbayiSangay WangmoSarah DawsonSarah Eldert Brownsarah.whitehead@bannerhealth.comsarah@fellowshipcouncil.orgsaritas204@gmail.comsarkariais@upmc.eduSary Hatem AbdallahSashaschauep@ccf.orgsfoungaristosst@gmail.comSharona Rossshart1@health.usf.eduShehab MohamedShelly JordanShelly McCabeSherif Mohammed Adel Aljoulanysherry.dwyer@bmioftexas.comshilpagb@yahoo.comshivamvatsal@gmail.comshorgan@ucsd.edushwnstn@gmail.comsiddarthgoudar1985@gmail.comsjharidarshan@gmail.comsjlin@bidmc.harvard.edusmarecik@hotmail.comsmitdeni@upstate.edusmorton@uabmc.eduSnezana Lukacsnkothar@gundersenhealth.orgsorellana@tgh.orgspaniolask@ecu.eduspartridge@partners.orgsramamoorthy@ucsd.eduStacey SuStacy BrethauerStacy Matthewsstan.rogers@ucsfmedctr.orgstocktonb@health.missouri.eduSubhash Kinisundarms74@rediffmail.comsunniy042401@hotmail.comsunny.jen@uci.edusurgeon_n@hotmail.comsurgeonpervez@gmail.comsuzie.smeaton@carolinashealthcare.orgtaaloia@mdanderson.orgtaj@timothyjessiemd.comTamer Abou Youssiftankavinash@gmail.comTanya RolfTatianne Moreira da Costatburrell@lifebridgehealth.orgtduncan@peachtreebariatrics.comTeh Mei SzeTemilolaoluwa Olanrewaju DaramolaTest Accounttfarrell@med.unc.edutfullum@howard.eduthadeus.trus@hitchcock.orgthakuriyaa@gmail.comthalia_pet@hotmail.comtitusduncan@gmail.comtms4h@virginia.eduTommi Kalle Markus Järvinentretojack@gmail.comtrey.blazer@duke.edutsloan@uky.eduupadhya@sutterhealth.orgussai.silvia@gmail.comVal Catalasanvaldezs2@uthscsa.eduVanessa CheungVanessa SantosVelma MontemayorVena Addisonvogelj@ccf.orgvrutkowski@njhf.orgvslunake@iupui.eduvzdoctor@rambler.ruWalshm@ccf.orgWanda F Carrwgeis@lifebridgehealth.orgwilliam.inabnet@mountsinai.orgwolfekc77@gmail.comyavuzay@istanbul.edu.trydocisin@aol.comyinliu204@hotmail.comZahid Aslam ShivaniZiad T Awadzkhorgami@med.miami.eduzografaj@summahealth.orgThank you, , for your interest in the SFFC program. Grant Requirements Institutions who have programs accredited for post-graduate level surgeons seeking clinical training in the surgical disciplines of Bariatric Surgery, Bariatric/MIS Surgery, Colorectal Surgery, HPB Surgery, MIS General Surgery and Thoracic Surgery. Applicants may apply specifically for a robotic-focused fellowship within one of the six disciplines. Fellowship programs must be primarily minimally invasive. Fellowship programs must be accredited by The Fellowship Council. Certain fellowship programs with ACGME accreditation, which do not receive CMS funding, may be considered. Funds are available for fellowship programs in the United States only. Institutions may apply for multiple fellows in different disciplines, but a separate application must be submitted for each discipline. Submission of a $100 non-refundable fee per application. Please select the fellowship discipline for this application(as accredited by the fellowship council)* Bariatric Bariatric/MIS Colorectal HPB MIS General Surgery Thoracic Acceptance of FSF Granting Policy Please check each box to accept the conditions. You must do this before beginning an application.01. Being a prior recipient of Fellowship funding from the Foundation for Surgical Fellowships does not guarantee funding for future Fellowship years.* I understand and agree to the above. 02. Completing the application does not guarantee a fellowship grant. Final determination is based on review results, availability of funds and areas of focus.* I understand and agree to the above. 03. Fellowship funding can only be awarded to accredited programs and not individuals.* I understand and agree to the above. 04. The Foundation for Surgical Fellowships reserves the right to confirm any submitted information and to reject or reduce points for any application completed with false data.* I understand and agree to the above. 05. The Program Director agrees to allow the FSF to access and cross-reference both Accreditation and Case Log information with the Fellowship Council and/or non-CMS funded ACGME programs.* I understand and agree to the above. 06. The Foundation for Surgical Fellowships will only consider applications from accredited Fellowship Programs based in the United States.* I understand and agree to the above. 07. Brand-new programs that are in-process for full accreditation with The Fellowship Council shall not be eligible to receive funding if not fully accredited prior to the fellowship year start date.* I understand and agree to the above. 08. The fellowship program's accreditation status must be in good standing with The Fellowship Council or ACGME.* I understand and agree to the above. 09. There is a non-refundable $100 application fee for each application submitted for review. Failure to pay the fee will result in the application not being reviewed.* I understand and agree to the above. You cannot continue until you agree to all nine statements aboveWould your fellowship program like to be considered for a Robotics grant if it qualifies?*Note: Selecting "Yes" allows us to access other funding pools under which to consider your program for a grant. It will not increase the number of grants you receive. More information will follow for those who qualify. Yes No Was elective surgery restricted for your fellow(s) due to COVID-19 in the 2019-2020 academic year (ending July 31, 2020)?* Yes No If your answer to the question above was yes please indicate the start and end date of the restriction below.Start Date Month Day Year End Date Month Day Year Fellowship Positions01. How many total fellow positions, including non-accredited, are in this program?*01234502. How many of these positions are accredited by the Fellowship Council?*01234503. How many of these positions are accredited by the ACGME?*01234504. How many fellowship positions is your program requesting funding for with this grant application?*012345 Fellowship Program Director01. Name of Institution (e.g. XYZ Medical Center)* 02. Department Name (e.g. Department of XYZ)* 03. Program Director Name* First Name Last Name 04. Program Director Degree(s) (e.g. MD, DO, PhD)* 05. Program Director Business Phone*06. Program Director Email* 07. Program Director Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Fellowship Associate Program Director01. Associate Program Director Name* First Name Last Name 02. Associate Program Director Degree(s) (e.g. MD, DO, PhD)* 03. Associate Program Director Phone Number*04. Associate Program Director Email* Program Coordinator or Administrative01. Program Coordinator or Administrative Name* First Name Last Name 02. Program Coordinator or Administrative Phone*03. Program Coordinator or Administrative Email* Grants Office Contact Information01. Grants Office Contact Name* First Name Last Name 02. Grant Office Contact Phone Number*03. Grant Office Contact Email* 04. Grant Office Organization (e.g. XYZ Medical Center)* 05. Grant Office Department* 06 Grant Office Contact Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Primary Contact for Correspondence01. Who is the primary contact for this grant application?*Please select one from the dropdown menu.Program DirectorAssociate Program DirectorFellowship Coordinator/PD AdminGrant ProfessionalCheck Disbursement Information01. If accepted, Grant Payment Check should be made out to:*This must be an institution or corporation. We cannot issue checks to individuals. 02 Type of Institution* Private Practice Academic If Other, please explain: 03. Tax Status of Institution* For profit Non profit Not-for-profit 04. Federal Tax ID* 05. Grant Check Attention Name* First Name Last Name 06. Grant Check Contact Phone Number*07. Grant Check Contact Email* 08. Grant Check Mailing Options* by Regular Mail via Fedex 08-a. Grant Check Regular Mailing Information*Please provide this information correctly. Thanks! Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 08-b. Grant Check Fedex Mailing Information*Please provide the shipping address (NO PO boxes). Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 06. Please provide any additional instructions regarding payments, if applicableAdditional Program Information01. Years of Experience as Fellowship Program Director at your current program*02. Has the Program Director ever run a similar program?* Yes No 03. Where?* 04. Start Year*20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197005. End Year*2020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197106. Total Years of Experience as Fellowship Program Director*07. Please indicate the total number of primary faculty surgeons contributing to training*(please include the Program Director in this total)08. Additional Primary Faculty/Surgeons contributing to training (one per line)A primary faculty surgeon is defined as one that has regular and consistent interaction and participation in the training of the Fellow(s) Program Information/Accreditation02. Is this a brand new program?A brand new program is defined as any program that has not yet graduated a fellow. Programs which currently have their first fellow(s) are considered brand new programs as a full year of case logs is not yet available for review. Yes No You will need to submit a Case Load Summary Chart and upload the Program Director’s Case Logs for the last full academic year.04. How many years has this Fellowship Program been in existence?*05. How many fellows have completed this fellowship program to date?*06. Is the requested position(s) accredited by the Fellowship Council?* Yes No 07. Fellowship Council ID (FCID)* 08. Year when first accredited by The Fellowship Council*20202019201820172016201520142013201220112010200920082007200620052004200320022001200009. What is the institution's current accreditation status with The Fellowship Council?* 1 year 2 year 3 year 10. Have you ever been placed on probation by The Fellowship Council?* Yes No 11. Year Placed on Probation*Please enter a number from 2000 to 2020.12. Year Probation EndedIf currently on probabtion, leave this field blankPlease enter a number greater than or equal to 2000.13. Is the requested position accredited by the ACGME?* Yes No Programs that not accredited by The Fellowship Council nor the ACGME are not eligible for funding01. Does the ACGME-accredited program receive CMS funding?* Yes No Programs that receive CMS funding are not eligble to receive funds from the FSFACGME Accreditation Number* Date when first accredited by the ACGME* MM slash DD slash YYYY What is the institution’s current accreditation status with the ACGME?*1 year2 year3 year4 year5+ yearHave you ever been placed on probation by the ACGME?* Yes No When?* What was the major citation(s)?* Will these funds be used to support an ACGME approved surgical resident?* Yes No Will the faculty be shared or separate?* Shared Separate Would this funding supplement an existing ACGME-approved CRS at your institution?* Yes No Will the faculty be shared or separate?* Shared Separate Does your institution have, in addition to this fellowship(s), ACGME-approved colon and rectal surgical residents?* Yes No Does the RRC for CRS know of and approve this additional training slot?* Yes No Will the faculty be shared or separate?* Shared Separate Is the Institution designated as a Bariatric Surgery Center of Excellence?* Yes No Not applicable Please select all that apply from the list below* Yes, by ACS In process with ACS Yes, by ASMBS/SRC In process with ASMBS/SRC Yes, by Blue Cross/Blue Shield In process with Blue Cross/Blue Shield Please share any other pertinent information that relates to your program or accreditation here: Program Curriculum and FundingWill the fellow attend and/or participate in any additional educational activities or career mentoring/development in or outside the institution? Yes No Please name any Academic Conferences or Workshops a fellow in your program would attend.*The program has a mechanism in place to evaluate the competency of the fellow participating in the program. Yes No The fellowship curriculum documents both the educational and clinical objectives for the program. Yes No Please give details for the evaluation and educational objectives used as stated in the above two answers: (100 words or less)For approximately how many hours per week will the fellow receive surgical technical skills training in each of the following settings (use a zero to indicate no participation): Intra-operative*Please enter a number greater than or equal to 0.Animate Lab*Please enter a number greater than or equal to 0.Inanimate Lab*Please enter a number greater than or equal to 0.Other*Please enter a number greater than or equal to 0.How many faculty members, other than the Program Director, will be doing surgical technical skills training with the fellow?*Have any fellows or the Program Director invented or participated in any preliminary innovation within the training discipline?* Yes No Please explain the project and specify whether the staff involved were fellows or directors:*How do you ensure that your fellow is prepared for independent practice by the completion of fellowship training?*Does your fellow perform any cases in the attending/faculty role?* Yes No Please explain in 100 words or less:*Do you currently receive funding from sources, including your own institution or practice, other than the FSF to support the salary of the fellow(s)?* Yes No If yes, please list sources of funding below and include the percentage each source (other than the FSF) covers of the total costs to be able to train one Fellow at your organization.*Does your institution offer matching funds on grants given?* Yes No Does your fellow bill independently for cases?* Yes No How much is allowed?* Fellowship expense breakdownPlease note: No overhead expenses are permitted to be included. If you are requesting funding for more than one fellow, please only enter the salary for ONE fellow here.Salary*Travel*Fringe Benefits*Malpractice*Total Request Scholarly ActivitiesPeer Reviewed Journal Articles1. Number of peer reviewed journal articles published between 1/1/2018 and 12/31/2020. Do not include article without PubMed IDs (PMID) in the counts. PMID is a unique number assigned to each PubMed record. This is generally an 8 character numeric number. IMPORTANT: In section 7, you will be required to upload a document listing the (PMID) and publication date for each article included in the counts below. Faculty is Author/Presenter2020 Faculty Journal Articles*Please enter a number from 0 to 150.2019 Faculty Journal Articles*Please enter a number from 0 to 150.2018 Faculty Journal Articles*Please enter a number from 0 to 150. Fellow is Author/Presenter2020 Fellow Journal Articles*Please enter a number from 0 to 150.2019 Fellow Journal Articles*Please enter a number from 0 to 150.2018 Fellow Journal Articles*Please enter a number from 0 to 150.National/International Conference Presentations2. Number of abstracts, posters, and presentations given at international or national meetings between 1/1/2018 and 12/31/2020. IMPORTANT: In section 7, you will be required to upload a document listing the presentations in the counts below. Faculty is Author/Presenter2020 Faculty Inter/National Presentations*Please enter a number from 0 to 150.2019 Faculty Inter/National Presentations*Please enter a number from 0 to 150.2018 Faculty Inter/National Presentations*Please enter a number from 0 to 150. Fellow is Author/Presenter2020 Fellow Inter/National Presentations*Please enter a number from 0 to 150.2019 Fellow Inter/National Presentations*Please enter a number from 0 to 150.2018 Fellow Inter/National Presentations*Please enter a number from 0 to 150.Regional / Local Conference Presentations3. Number of abstracts, posters, and presentations given by faculty and/or fellows at regional or local meetings between 1/1/2018 and 12/31/2020.Do not include invited lectureships, grand rounds, etc, in the count.Total Regional / Local*Other Presentations4. Number of other presentations given (e.g. grand rounds, invited professorships, etc) by faculty and/or fellows between 1/1/2018 and 12/31/2020. Total Other*Book/Chapters, Technical Papers, Review Articles, etc5. Number of Chapters or Textbooks published, materials developed (such as computer-based modules), or work presented in non-peer review publications by faculty and/or fellows between 1/1/2018 and 12/31/2020. Articles without PMIDs should be included as well. This will include publications which are peer reviewed but not recognized by the National Library of Medicine.Total Published* Upload Case Load Chart(s)Because you indicated this is a brand-new program, we need you to fill out and upload the FSF Case Load Chart for the following people: The current program director The associate program director The most recent past fellow(s), if any Please use this template and create a new file for each person. Thank you.Case Load Charts*Uploaded case logs do not have a "save and continue" option. Please upload case logs only when you are ready to make your payment and submit your application. Drop files here or Select files Accepted file types: xls, xlsx, pdf, doc, docx, csv, txt, Max. file size: 512 MB. Program Director's Verification of Accuracy* It is certified by marking this box that the case numbers submitted in this chart have been tabulated and reviewed by the Program Director for final approval and accuracy. Document UploadsUploaded case logs do not have "save and continue" option. Please upload documents only when you are ready to make your payment and submit your application.Upload Program Director CV*Accepted file types: pdf, doc, docx, zip, rtf, Max. file size: 512 MB.Upload PubMed IDs / Journal Information File*1. Please provide a listing of PubMed IDs (PMID) and publication year for Peer Review Journal Articles published between 1/1/2018 through 12/31/2020. PMID is a unique number assigned to each PubMed record.This is generally an 8 character numeric number. Do not include articles without PMIDs. This listing should correspond with the counts provided in the Scholarly Activity Section and can be an existing document (e.g. CVs) or by using the template provided below.Accepted file types: xlsx, xls, doc, docx, pdf, zip, Max. file size: 512 MB.Upload PubMed ID/Journal Information using this template Upload Conference Details*2. Please provide a listing of National and International Conference Presentations from 1/1/2018 through 12/31/2020. The listing should correspond with the counts provided in the Scholarly Activity Section. Do not include regional or local conference presentations, or any other presentations in this list. The document can be an existing document (e.g. CVs) or via the template provided below.Accepted file types: xlsx, xls, doc, docx, pdf, zip, Max. file size: 512 MB.Upload Conference Details using this templateUpload Case Logs* Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, Max. file size: 512 MB. Application Fee Payment Type*There is a $100 application fee due for this application. How do you wish to pay? 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Your receipt will be located at the very bottom of your submitted application PDF.Check Payment Please note that your check must be received by February 21, 2021 in order for your application to be processed. Please send your $100 check payment (payable to The Foundation for Surgical Fellowships) to: Foundation for Surgical Fellowships ATTN: 2022-2023 Application 11300 W. Olympic Blvd, Suite 600 Los Angeles, CA 90064 Please reference your FCID # or ACGME # on the check. Thank you! You have reached the end of the application! If you submit this application now, you will NOT be able to edit it after submission. In order to submit, click the Preview button below, review your data and click “Submit”. If the information is not correct, either use the navigation at the top of the form to jump to different sections or use the "Save and Continue" link to save your data and return later. {all_fields} Δ