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SSAT CGS Fellowship Certificate Application
Contact Information
Please enter your contact information.
First Name
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Middle initial:
Last Name
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Please enter your suffix (ex: MD, PhD, etc.)
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Institution / Program Name
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Street Address
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Address Line 2
City
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State/Province/Region
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Zip/Postal Code
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Phone Number
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Country
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Permanent Email Address (not your institution)
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Certificate Application Questions
Year of Completion
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Program Director First Name
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Program Director Last Name
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Program Director Email Address
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Are you an SSAT member?
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Yes
No
Please enter you Member ID #
Have you attended DDW this past year?
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Yes
No
Please upload proof of attendance at DDW (badge, confirmation email, etc.).
Have you submitted an abstract to DDW this past year?
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Yes
No
Please upload proof of abstract submission to DDW.
Have you submitted a manuscript from your SSAT CGS Fellowship Grand Rounds presentation to JOGS?
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Yes
No
Please upload proof of manuscript submission to JOGS.
Have you completed other scholarly activity this year? ie. Abstract, poster, presentation, journal article or book chapter
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Yes
No
Please upload proof of scholarly activity.
Did you attend at least 50% of the SSAT CGS Fellowship Grand Round presentations?
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Yes
No
Did you present a SSAT Advanced GI Fellowship Grand Round presentation?
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Yes
No
Please upload your presentation file.
Have you completed the minimum 150 cases required?
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Yes
No
Please upload your case logs.
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