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   Please fill out the following demographic information: (if this is incomplete, there will likely be a delay in completing your signup.) ALL INFORMATION IS KEPT STRICTLY CONFIDENTIAL.

   1) When are you scheduled to take, or anticipate taking, the written exam? -Date you are expecting to take the written- August 2011 Not sure, probably in 2011 Not sure, probably in 2012 Not sure, probably in 2013
If you are not yet sure when your orals will be scheduled, you may indicate your estimated exam date in the Additional Information section below.

   2A) Have you taken the general surgery written exam in the past?     Yes        No
      If yes, how many total attempts? -Number of total attempts- 1 2 3 4 5 6
      If yes, when was/were your attempt(s)? Please click all that apply.

2010 2009 2008 2007 2006 2000 or earlier Dates of other prior exams

   3) Please indicate the year you completed or anticipate completing general surgery training:     -Year you completed or anticipate completing GS training- 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 prior to 2000

   4) Please give the name of your general surgery residency program, city, and state, as well as your medical school.

   Residency Program Name/Location
      

   Medical School Name/Location
      

   5) Is/Was your program academically or community based?
    Mostly or completely academic
    Mostly or completely community
      How many chiefs in your training program?     -Number of Chiefs- 1 2 3 4 5 6 7 8 9 10

   6) Do you have any area(s) of additional training? Select all that apply.

No fellowship Trauma Vascular Critical Care Thoracic Cardiothoracic

Transplant Laparoscopic/Minimally Invasive Plastics Colorectal Breast Hand Other (please specify)

   If you did or are doing a fellowship, please give name and location of program.

   

   7) Did you have mock orals in your General Surgery training?    Yes       No
      If Yes, you did have mock orals in training, please specify the following:
       a) -Frequency of Mock Orals- once a year twice a year three times a year four times a year every month every week Other -- please specify in Additional Thoughts about Your Mock Orals field below
       b) -What Years Were Your Mock Orals Given- PGY 5 only PGY 4 only PGY 3 only PGY 4 and 5 PGY 3 and 4 and 5 every year Other -- please specify in Additional Thoughts about Your Mock Orals field below
       c) -Who Conducted Your Mock Orals in Training- Experienced faculty Inexperienced faculty Both experienced and inexperienced faculty Other -- please specify in Additional Thoughts about Your Mock Orals field below
       d) -Were Your Mock Orals in Training Within or Outside the Institution- Within the institution only Outside the institution (with surgery faculty from other surgery programs in the area) only Both within and outside the institution Other -- please specify in Additional Thoughts about Your Mock Orals field below
       e) -Structure of Your Mock Orals in Training- 1, nothing like the actual exam 2 3 4 5 6 7 8 9 10, exactly like the exam (3 rooms with 2 examiners per room, each room lasting 1/2 hour) Other -- please specify in Additional Thoughts about Your Mock Orals field below
       f) How would you rate the value of faculty feedback to you during your mock orals in training? (0 is "no feedback," 1 is "extremely poor feedback," and 10 is "extremely beneficial and useful feedback." -Your Feedback From Faculty during Your Mock Orals in Training- 0, no feedback 1, extremely poor feedback 2 3 4 5 6 7 8 9 10, extremely beneficial feedback
       g) Overall, how would you rate their value? (1 is worst, 10 is best) -Overall Value of Your Mock Orals- 1 2 3 4 5 6 7 8 9 10

   Additional thoughts about your mock orals in training.
   

   8) How old are you?    Age

   9) How would you describe your current status in practice? -Current Status in Practice- Attending, private practice Attending, academic practice Attending, private/academic mix Fellow PGY 5 Resident PGY 4 Resident PGY 3 Resident PGY 2 Resident PGY 1 Resident

   10) How did you hear about Odyssey? Select all that apply.

Postcard Referral (Please indicate who referred you.) Did you try an Internet search?   What search engine did you use?     -Search Engine- AltaVista AOL search Google MSN Netscape Yahoo Other     If Other, please specify other search engine     Please indicate your search terms.     Was your internet search successful in finding Odyssey?       Yes    No  Other source (Please specify.)

   Tell us additional information about your request: