American Board of Surgery TBSCCB Nomination Form

First Name ^* (required)

Last Name ^* (required)

E-mail Address ^* (required)

Please list a phone number for AAST Staff to contact you ^* (required)

1. Do you have Educational Assessment experience? ^* (required)

Yes

No

If yes, please add additional information.

2. Do you have Education Innovation competency? ^* (required)

Yes

No

If yes, please add additional information.

3. Do you have competency in the development of certification and accreditation? ^* (required)

Yes

No

If yes, please add additional information.

4. Do you have competency with Entrustable Professional Activities (EPAs)? ^* (required)

Yes

No

If yes, please add additional information.

5. Do you have community practice experience? ^* (required)

Yes

No

If yes, please add additional information

6. Do you have burn/wound care experience? ^* (required)

Yes

No

If yes, please add additional information.

7. Do you have emergency critical care experience? ^* (required)

Yes

No

If yes, please add additional information.

Upload your CV ^* (required)

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