The American Council of Academic Plastic Surgeons has initiated an outcomes project to
gather longitudinal data for the purposes of improving plastic surgery training. To help your
program complete its data entry, please provide the following information. Because this outcomes
project is new, some of the information must be entered separately for each year you have been in
the program, allowing us to fill our database for previous years. In the future, you will only be
asked to update this information for the most recently completed year. Please return the
completed form to your program director. If you have any questions, please contact your program
director or program coordinator. Thank you for your help in improving plastic surgery training.
**Complete this form once for EACH YEAR you have COMPLETED in the program.**
Your name: __________________________________
Academic year for the data you are providing (e.g., 2003-2004): ____________
For INDEPENDENT/COORDINATED residents, indicate your PGY level for the academic year
indicated above. If you were in the lab this year, circle lab/research
PGY1
PGY2
PGY3
lab/research
For INTEGRATED residents, indicate your PGY level for the academic year indicated above.
If you were in the lab this year, circle lab/research
PGY1
PGY2
PGY3
PGY4
PGY5
PGY6
lab/research
If you were in a lab/research year for the academic year indicated above, what was the last
PGY level of clinical training you completed prior to entering the lab?
PGY1
PGY2
PGY3
PGY4
PGY5
PGY6
For INDEPENDENT/COORDINATED residents, in what specialty was your prerequisite
training?
_______________________________________
For the academic year indicated above, how many months of experience did you have on
each of the following services?
Plastic Surgery
General Surgery
Vascular Surgery
Pediatric Surgery
Otolaryngology (ENT)
Oral/maxillofacial Surgery (OMFS)
Orthopedic Surgery
Oculoplastic Surgery
Anesthesia
Dermatology
For the academic year indicated above, how many of each of the following did you
accomplish?
National podium presentations
National poster presentations
Regional podium presentations
Local podium presentations (do not include conferences that are part of the
residency program)
Manuscripts accepted for publication in peer reviewed journals
Book chapters
Invited articles
Internally funded research grants
Externally funded research grants
Committee membership for a national professional organization
Committee membership for a local or regional professional organization
Local or regional medical volunteer work (indicate the number of
organizations for which you volunteered)
International medical mission trips