FELLOWSHIP PROGRAM DIRECTOR REFERENCE FORM FOR SENIOR MEMBERSHIP APPLICANTS

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Please Enter the Sponsor’s Information:

First Name:
Middle Name:
Last Name:
Degree:
Email:
Phone: - - ext.:

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.
Senior Members in the Society of NeuroInterventional Surgery are required to:
  • Have one year subspecialty training in interventional neuroradiology, endovascular neurosurgery or interventional neurology;
  • Be board certified or eligible by the American Board of Medical Specialties, the Royal College of Physicians and Surgeons of Canada, or other Board or Tribunal which, in the judgement of the Executive Committee, is of equivalent rank;
  • Have had direct involvement in a minimum of 100 neurointerventional procedures during their training; and

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?
 
4. During the applicants training period, approximately how many neurointerventional cases was he/she directly involved in?
 
5. To the best of your knowledge, would you judge the applicants medical knowledge to be:
 
6. To the best of your knowledge, would you judge the applicants technical skills to be:
 
7. To the best of your knowledge, would you judge the applicants clinical judgment to be:
 
Do you feel that the applicant is as a Senior Member of SNIS?
Comments:
***This reference is considered confidential to the extent permitted by law.