Preceptee Faculty Survey

1. First name: 2. Last name:
3. Email address:
 
4. Office Phone no. Cell Phone no.
5. Preferred method of correspondence: email | office phone | cell phone
 
6.
I am an: AAPS Member
ASPS/ASAPS Member
 
7. Plastic Surgery Residency:
Date Completed:
 
8. Fellowship No. 1
Subspecialty:

Program:
Date Completed:
 
9. Fellowship No. 2
Subspecialty:

Program:
Date Completed:
 
10. Present Institution
Program:

Academic appointment:
Date Started:
 
11. Clinical Focus:
 
12. Research Focus
Investigative interests: Clinical:

Investigative interests: Basic Science:
 
13. Please list specific areas in which you would like guidance by a mentor outside of your institution:
 

 
 
American Association of Plastic Surgeons
500 Cummings Center, Suite 4400, Beverly, MA 01915
Phone: 978-927-8330 | Fax: 978-524-0498