Communication Skills Mentoring Program Application Form
This application form is estimated to require 10 minutes to complete.
**All fields are required. Please enter N/A if "Not Applicable."
Part I:
Host Organization/Institution Information
What is the purpose for requesting an AAOS sponsored Communication Skills Mentoring Program workshop at your organization/institution?
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Is your organization/institution considered
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Please Select
an Orthopaedic Residency Program
a State Orthopaedic Society
an Orthopaedic Specialty Society
Other
Name of Organization/Institution:
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Location: (Address, City, State, and Postal Code)
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Orthopaedic Residency Program Director"s Name & Contact Information:
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Orthopaedic Residency Program Chair"s Name & Contact Information:
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Orthopaedic Residency Program Coordinator"s Name & Contact Information:
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State Orthopaedic Society President"s Name & Contact Information:
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State Orthopaedic Society Executive Director"s Name & Contact Information: (If there are 2 Executive Directors, please provide the names and contact information of both)
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Orthopaedic Specialty Society President"s Name & Contact Information:
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Orthopaedic Specialty Society Executive Director"s Name & Contact Information: (If there are 2 Executive Directors, please provide the names and contact information of both)
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Name & Contact Information of Primary/Main Contact for Scheduling a CSMP Workshop:
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Part II: Communication Skills Training
Has your organization/institution provided training in communication skills?
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Please Select
Yes
No
If you answered "yes," what type of communication skills training was conducted?
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Please Select
An AAOS provided Communication Skills Mentoring Program workshop
Other
If the training was an AAOS provided Communication Skills Mentoring Program workshop, what is the most recent date of the last workshop presented at your organization/institution?
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Month
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Day
Year
Date
If your organization/institution provided a different form of communication skills training, please describe the type of training that was conducted.
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When is your next RRC review? (Only applicable to Orthopaedic Residency Programs)
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Month
-
Day
Year
Date
What are your expectations for hosting an AAOS provided Communication Skills Mentoring Program workshop?
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If an AAOS provided Communication Skills Mentoring Program workshop is held at your organization/institution, what is your plan for ongoing communication skills training and implementation?
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Part III: Workshop Scheduling Information
How many workshops would your organization/institution like to host?
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Please Select
1 workshop
2 workshops
More than 2 workshops
Other
When would your organization/institution like to host an AAOS provided Communication Skills Mentoring Program workshop(s)? (Please indicate up to 4 potential date options and number them in order of preference (Date Option #1- Date Option #4))
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What time would you like to host an AAOS provided Communication Skills Mentoring Program workshop(s)
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Please Select
In the morning (8:00 am - 12:00 pm)
In the afternoon (12:00 pm - 4:00 pm)
Other
Who is the Communication Skills Mentoring Program workshop for?
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Please Select
Orthopaedic Residents and Faculty
Orthopaedic Surgeons in Practice
Other
Approximately how many participants do you anticipate attending each Communication Skills Mentoring Program workshop?
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Please Select
Less than 20 participants
20-25 participants
More than 25 participants
Other
Part IV: Additional Information
If AAOS should have any questions regarding this application form, what is the applicant"s name and contact information?
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Other Questions/Comments:
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