Step 1 of 2 50% Please report any problems with this form to [email protected]Writer Name(Required) First Last Writer Email(Required) Are you a member of AHNS?(Required) Yes No Applicant Name(Required)In reference to this applicant's application for AHNS membership, would you be willing to comment on his/her professional competence and character?(Required) Yes No If not, why not?(Required) How long have you known this applicant professionally?(Required)Did you work with the applicant during his/her fellowship?(Required) Yes No In what capacity?(Required) Fellowship Director Faculty Research Mentor Other Is the applicant's practice within the scope of the AHNS?(Required)(e.g. actively engaged in diagnosis, treatment, and rehabilitation of patients with neoplasms and other diseases of the head and neck and the prevention of neoplasms and other diseases of the head and neck) Yes No Have you assisted the applicant, or has the applicant assisted you, at surgery?(Required) Yes No Do you know of any adverse (reportable) action taken in the past or present or is pending which could limit or restrict the applicant's medical license or hospital staff privileges (including required supervision or monitoring) at any hospital?(Required)If yes, please provide additional information in the comment box at the bottom of the application and/or attach appropriate documentation. Yes No What is your opinion as to the applicant's...(Required)ExcellentGoodAverageFairPoorSurgical and clinical judgement?Professional and ethical conductDo you support this person's application for AHNS membership?(Required) Yes, without reservation Yes, with reservation (add comment in below comment box) No (add comment in below comment box) Please add any comments or concerns regarding the applicant here.This information will only be seen by the AHNS office and Membership & Credentials Service Please upload any additional files/documentation if needed. Drop files here or Select files Max. file size: 512 MB. Δ Share: Click to share on Facebook (Opens in new window) Facebook Click to share on X (Opens in new window) X Click to share on LinkedIn (Opens in new window) LinkedIn
