SURVEY TO ASSESS FEASIBILITY FOR HOSTING BRACHYTHERAPY OBSERVER FELLOWS
1. Name of Institution *
Your answer
2. City/State/Country *
Your answer
3. Primary point of contact (clinical) *
Your answer
4. Primary point of contact (administrative/email) *
Your answer
5. Types of brachytherapy performed at the institution (Select all that apply)
5 a. Please indicate the average per year per by disease site/procedure.
Your answer
6. Number of faculty performing various types of brachytherapy
7. Is your institution interested in hosting local/national/international visitors to observe brachytherapy procedures?
7 a. If you answered yes to question 7 please briefly list if Local only, Local/National only or Local/National/International for type of visitors you are interested in hosting.
Your answer
If you answered yes to Q7, then proceed to questions 8 – 13, If No, then proceed to question 14.
8. Does your institution have a residency training program?
9. Does your institution have a fellow training program?
9 a. If you answered yes to question 9 please list which fellowships does your department offer.
Your answer
10. Does your institution currently host local/national/international visitors?
10 a. If you answered yes to question 10 please list if Local only, Local/National only or Local/National/International for type of visitors you host.
Your answer
11. Does your institution currently have existing international collaborations for exchange of observers (uni- or bi-directional)?
11 a. If you answered yes to question 11 please list names.
Your answer
12. Do you anticipate any unmanageable administrative hurdles in hosting observers?
13. Does your institution have a mechanism to assist national/international visitors (eg assistance with visiting hospital privileges, travel, room and board)?
13 a. If you answered yes on question 13 please describe.
Your answer
14. What would be your institution’s preferred duration for observers
15. Would providers in your institution be interested in funding and have self/institutional/other funding options to visit other centers for the purpose of providing brachytherapy mentorship?
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