Page 1 of 4 Fellowship Feedback Form This is a confidential evaluation form, which will be reviewed by the AOSpine Asia Pacific Officer for Spine Centers & Fellowships. This evaluation form must be completed within 30 days of conclusion of the fellowship. Fellow information First name Last name Member No. Nationality Fellowship details Host Spine Center Spine Center Director First name Last name Date of fellowship (dd/mm/yyyy) From / / To / / Name of other supervising surgeons Primary language spoken at Spine Center Performance scale Using the scale below, indicate your assessment of the extent to which the center demonstrated each capability. 1 Did not meet expectations 2 Partially met expectations 3 Met expectations 4 Exceeded expectations 5 Consistently exceeded expectations Environment 5 4 3 2 1 How satisfied were you with the availability and functionali ty of the center equipment? How modern was the technology used by the center? How suitable were the working conditions in the center? (ie, cleanliness, safety, space availability and lighting, etc) Overall, how well did the center environment meet your expectations?
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Fellowship Feedback FormThis is a confidential evaluation form, which will be reviewed by the AOSpine Asia Pacific Officer forSpine Centers & Fellowships. This evaluation form must be completed within 30 days of conclusionof the fellowship.
Fellow information
First name Last name
Member No. Nationality
Fellowship details
Host Spine Center
Spine Center Director
First name Last name
Date of fellowship (dd/mm/yyyy) From / / To / /
Name of other supervising surgeons
Primary language spoken at Spine Center
Performance scaleUsing the scale below, indicate your assessment of the extent to which the center demonstrated eachcapability.
1 Did not meet expectations2 Partially met expectations3 Met expectations4 Exceeded expectations5 Consistently exceeded expectations
Environment5 4 3 2 1
How satisfied were you with the availability and functionality of the center equipment?
How modern was the technology used by the center?
How suitable were the working conditions in the center? (ie, cleanliness, safety, space availability and lighting, etc)
Overall, how well did the center environment meet your expectations?