Step 1 of 2 50% Please report any problems with this form to [email protected]Sponsor Name(Required) First Last Sponsor Email(Required) Are you a member of AHNS?(Required) Yes No Fellow Name(Required)Fellow Class(Required)Which class is the fellow upgrading to? Active (within USA or Canada) Corresponding (outside of USA or Canada) In reference to this fellow's upgrade from Candidate to Active or Corresponding 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 fellow professionally?(Required)Did you work with the fellow during his/her fellowship?(Required) Yes No In what capacity?(Required) Fellowship Director Faculty Research Mentor Other Is the fellow'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 fellow, or has the fellow 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 fellow'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 fellow's...(Required)ExcellentGoodAverageFairPoorSurgical and clinical judgement?Professional and ethical conductDo you support this person's upgrade to Active or Corresponding 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
