Robotic Training Programme form | European Society of Coloproctology

“*” indicates a mandatory field.

Personal data

Name *

Surname *

Title

Academic Title

Other academic title

Date of birth *

Contact data

Email (main) *

Email (additional)

Mobile phone number *

Additional phone number

Institution

Insitution name *

Department *

Institution address street, number *

Institution address City *

Institution address Zip code *

Institution address Country *

Requirements / Qualification

How many years since you have finished your residency? *

How many year(s) have you been as a consultant (attending)? *

Do you have the EBSQ diploma in coloproctology? *

Yes No

How many colorectal resections did you perform in the last years? *

Please fill in the calendar years your refer to in line 1 (for example IF the current calendar year is 2021, fill in 2021, 2020, 2019, 2018) and the number of resections for this calendar years in line 2. Thanks.

	This year	Previous year	Year before last	2 years before last
Calendar year
Number of colorectal resections

Please summarize your experience of the last five years related to specific procedures below *

	Number of open procedures (last 5 years)	Number of laparoscopic procedures (last 5 years)	Number of robotic procedures (last 5 years)	Total number of procedures (last 5 years)
Right hemicolectomy
Sigmoidectomy
Low Anterior Resection

Can you provide a summary of audit data evaluating your clinical outcomes as per standard practice for the last 12 months? *

Yes No

Optional free text

Do you engage in regular clinical audits in line with your regional (country) practice? *

Yes No

Optional free text

Do you have access to at least one robotic platform? *

Yes No

How many robotic platforms do you have access to? *

Which type of platforms do you have and which model? *

DaVinci xi

DaVinci x

DaVinci si

Hugo

Versius

Senhance

other

Specify *

Do you have access to at least one robotic surgery simulation system? *

Yes No

Which simulation systems do you have access to? *

SimNow

Da Vinci Skills Simulator

3d systems Robotix Mentor

Other

Specify *

Is your institution supporting your application for attending the ESCP colorectal robotic training program? *

Yes No

Optional free text

Please provide a date when you have completed your basic technology training as console surgeon for the robotic platform (e.g. TR100, TR200 for da Vinci robot). If you are planning to complete the training, please provide a date.

Month *

Year *

What would be your earliest possible date to start the ESCP colorectal robotic training program? *

How many days per month do you have access to the robotic platform? *

Activity

For how long you have been a ESCP member?

In which country did you receive your medical degree? *

Which year/s you have attended the ESCP annual conference?

This year

Previous year

Year before last

2 years before last

3 years before last

How many publications do you have in peer reviewed journals in the field of Robotic Surgery (exclude case reports and conference abstracts)? *

How many publications do you have in peer reviewed journals in the field of coloproctology as first or second or senior author (exclude case reports and abstracts)? *