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ESCP Vilnius 27-29 September 2023
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ESCP 6-Month Fellowship Application
Your Details:
Name
*
Email
*
Work Address
*
Contact Number
*
Referee Details:
Referee Name
*
Referee Email
*
Referee Address
*
Relation to the Candidate
*
1. Age
How old are you?
*
<35 years
35-40 years
>40 years
2. ESCP membership
For how long you have been ESCP member?
*
<12 months
12-24 months
24-36 months
36-48 months
>48 months
3. Committees or young ESCP membership?
Are you member of ESCP committees or young ESCP?
*
Yes
No
4. Time from Graduation from medical school
How long ago you graduated from medical school?
*
<8 years
8-12 years
12-15 years
>15 years
5. Country of medical school
Which country you studied in for your medical degree?
*
Eastern Europe
Western Europe
Central Europe
Outside EU
6. Country of surgical practice
Which country you are practising in currently?
*
Eastern Europe
Western Europe
Central Europe
Outside EU
7. EBSQ
Have you passed EBSQ examination?
*
Yes
No
8. Attendance to ESCP annual conference?
Which year you have attended ESCP annual conference?
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
9. Time in colorectal surgery practice
How much time you have spent in colorectal surgery practice during and after completion of residency training?
*
<6 years
6-10 years
10-15 years
>15 years
10. Number of Publications
How many publications you had in the past 5 years in peer reviewed journals (exclude case reports and abstracts)?
*
0
1
2
3
4
5
11. Number of Publications in the field of coloproctology
How many publications you had in the past 5 years in peer reviewed journals in the field of coloproctology (exclude case reports and abstracts)?
*
0
1
2
3
4
5
12. Number of National/International Presentations in past 5 years
How many national/international poster presentations you had in the past 5 years?
*
0
1
2
3
4
5
>5
How many national/international oral presentations you had in the past 5 years?
*
None
1
2
3
4
5
>5
13. ESCP snapshot audits
Have you participated in ESCP snapshot audit?
Select all options if applicable.
None
2015
2016
2017
2018
2019
2020
2021
2022
14. Have you been awarded a fellowship by ESCP in the past
Have you been awarded a fellowship by ESCP in the past?
Select all options if applicable.
Pre-conference placement
KSCP travelling fellowship
JSCP travelling fellowship
ASCRS travelling fellowship
Observership
3 months fellowship
6 months fellowship
15. Operative experience past 5 years
Open right hemicolectomy: assisted
*
<10
>10, <20
>20
Open right hemicolectomy: supervised trainer scrubbed
*
<10
>10, <20
>20
Open right hemicolectomy: independent
*
<10
>10, <20
>20
Open segmental resection: assisted
*
<10
>10, <20
>20
Open segmental resection: supervised trainer scrubbed
*
<10
>10, <20
>20
Open segmental resection: independent
*
<10
>10, <20
>20
Open anterior resection: assisted
*
<10
>10, <20
>20
Open anterior resection: supervised trainer scrubbed
*
<10
>10, <20
>20
Open anterior resection: independent
*
<10
>10, <20
>20
Emergency laparotomy: supervised trainer scrubbed
*
<20
>20, <100
>100
Emergency laparotomy: independent
*
<50
>50, <100
>100
Laparoscopic appendicectomy: supervised trainer scrubbed
*
<20
>20, <50
>50
Laparoscopic appendicectomy: independent
*
<50
>50, <100
>100
Laparoscopic cholecystectomy: supervised trainer scrubbed
*
<20
>20, <50
>50
Laparoscopic cholecystectomy: independent
*
<50
>50, <100
>100
Laparscopic right hemicolectomy: assisted
*
<10
>10, <20
>20
Laparscopic right hemicolectomy: supervised trainer scrubbed
*
<10
>10, <20
>20
Laparscopic right hemicolectomy: independent
*
<10
>10, <20
>20
Laparoscopic anterior resection / left colonic resection: assisted
*
<10
>10, <20
>20
Laparoscopic anterior resection / left colonic resection: supervised trainer scrubbed
*
<10
>10, <20
>20
Laparoscopic anterior resection / left colonic resection: independent
*
<10
>10, <20
>20
Haemorrhoid surgery: supervised trainer scrubbed
*
<10
>10, <20
>20
Haemorrhoid surgery: independent
*
<10
>10, <20
>20
Fistula surgery: supervised trainer scrubbed
*
<10
>10, <20
>20
Fistula surgery: independent
*
<10
>10, <20
>20
16. Research Qualifications
Do you have any formal Research Qualifications?
*
None
PhD
Doctorate in Medicine (MD)
Number of research grants secured in the past 5 years as main applicant and co-applicant?
*
0
1
2
3
4
5
17. International Awards
Have you won any international awards for your work, presentations or research?
*
Yes
No
I confirm that above information is correct.
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I consent that ESCP uses my data for the purposes indicated in the
ESCP Privacy Policy
.
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ESCP Affiliates
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