Fellowship program director reference form for Senior membership applicants

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    Please enter the Sponsor's information:






    Please indicate the name of the person applying for membership:

    is applying for Senior membership status in the Society of NeuroInterventional Surgery and has listed you as a Neurointerventional Fellowship Program Director Reference.

    Neurointerventional fellowship program questionnaire:

    1. How long have you known the applicant?

    2. During what time period was the applicant a neurointerventional fellow under your direction?

    3. During that time period, approximately how many neurointerventional procedures were performed per year at the institution(s) where the applicant was training?
    <5050-100100-150150-200>200
    4. During the applicants training period, approximately how many neurointerventional cases was he/she directly involved in?
    <2525-5050-100>100
    5. To the best of your knowledge, would you judge the applicants medical knowledge to be:
    ExcellentAbove AverageAverageBellow AveragePoor
    6. To the best of your knowledge, would you judge the applicants technical skills to be:
    ExcellentAbove AverageAverageBellow AveragePoor
    7. To the best of your knowledge, would you judge the applicants clinical judgment to be:
    ExcellentAbove AverageAverageBellow AveragePoor

    Do you feel that the applicant is AcceptableUnacceptable as a Senior Member of SNIS?