SURVEY TO ASSESS FEASIBILITY FOR HOSTING BRACHYTHERAPY OBSERVER FELLOWS
1. Name of Institution
3. Primary point of contact (clinical)
4. Primary point of contact (administrative/email)
5. Types of brachytherapy performed at the institution (Select all that apply)
Liver-directed Microsphere Brachytheray
Please proceed to question 5 a and indicate the average per year
5 a. Please indicate the average per year per by disease site/procedure.
6. Number of faculty performing various types of brachytherapy
5 or more
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.
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.
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.
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.
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.
14. What would be your institution’s preferred duration for observers
As long as needed by observer
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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