Course Certification

Page 1 of 4

Course Certification Application

Applicant Information

Please provide pertinent contact information below.

First Name(*)

Invalid Input

Last Name(*)

Invalid Input

Email(*)

Invalid Input

Website

Invalid Input

If available, personal website or Bio page

Training Course Information

Center Name

Invalid Input

Center Street Address

Invalid Input

Address Line 2

Invalid Input

City

Invalid Input

State / Province / Region

Invalid Input

ZIP / Postal Code

Invalid Input

Country

Invalid Input

Course Director(s)(*)

Invalid Input

Instructor(s)(*)

Invalid Input

Course Start Date

Invalid Input

Course End Date

Invalid Input

Laparoscopy

Basic

Advanced

Invalid Input

Robotic Surgery

Basic

Advanced

Invalid Input

Type of Course

Endourology

Ureteroscopy

Percutaneous Nephrolithotomy

Both URS and PNL

Shock Wave Lithotripsy

Invalid Input

Course Sponsor(s)

Local Society

Invalid Input

Industry Sponsor(s)

Invalid Input

Course Details

Course Description

Invalid Input

Course Goals/Learning Objectives

Invalid Input

Explicitly state your course objectives and/or student learning outcomes. If additional text is needed, please include as an attachment.

Proposed Method of Assessment

Invalid Input

Please state the proposed method of assessment: (examples of subjective (OSATS, GEARS, etc.) examples of objective: automatic metrics derived from training system). If additional text is needed, please include as an attachment.

Course Resources

Other Resources

Invalid Input

Lodging available for attendees?

Yes

Other

Invalid Input

Previous Courses Offered

Course Materials

Course Details

Invalid Input

Please enter course details, including the title, instructors, start and end date (mm/dd/yy), number of attendees, website with any additional information, and the course fee charged.

Course Material Upload Instructions

Please provide the following documents to complete your Training Course Certification Application. The Faculty Disclosure and Credentials documents are required as part of your submission for a completed application.

Please upload a listing of Faculty Disclosures - required.
Please upload a listing of the faculty and their credentials. - required.
Please upload completed evaluation forms from previous courses - required.
Please upload written or audiovisual course material - required.
Please upload or provide link(s) to relevant syllabus or other online material - required.
Please upload and include documentation covering Metrics/errors, and Proposed Models - required.

Upload relevant course materials(*)

Invalid Input

If more than 5 files, attachments can be combined into a single file using a zip program, such as WinZip or 7zip, and uploaded. Please take note of the maximum upload file size.

Course Material Link(s)

Invalid Input

Provide link to syllabus or other available online material.