Radiologist Non-Clinical Productivity

Name *

First Name

Last Name

Start of Reporting Period

MM

DD

YYYY

End of Reporting Period

MM

DD

YYYY

Have you participated in non-clinical practice/radiology-related activities during the reporting period?

If your answer to this question is "yes" then please complete the rest of the questionnaire. If your answer to this question is "no" then scroll to the end and click on submit.

Yes

No

Have you given one or more conferences to our radiology residents?

If your answer to this question is "yes" then please provide more information regarding the conferences you have given. If your answer to this question is "no" then please skip ahead to the next topic.

Yes

No

Conference #1 Date

MM

DD

YYYY

Conference #1 Preparation

New Conference

Updated Conference

Conference #2 Date

MM

DD

YYYY

Conference #2 Preparation

New Conference

Updated Conference

Conference #3 Date

MM

DD

YYYY

Conference #3 Preparation

New Conference

Updated Conference

Have you given any conferences to residents/fellows outside of radiology?

Yes

No

Have you participated in a resident simulation session?

If your answer to this question is "yes" then please provide more information regarding your involvement in resident simulation sessions. If your answer to this question is "no" then please skip ahead to the next topic.

Yes

No

Have you accepted a formal assignment as a resident mentor?

Yes

No

Have you prepared letters of recommendation for residents in support of a fellowship application?

Yes

No

Have you given one or more conferences to medical students at AMC?

If your answer to this question is "yes" then please complete the information regarding the specific conferences that you have given. If your answer to this question is "no" then please skip to the next topic.

Yes

No

Have you participated in the AMC Radiology elective for medical students?

If your answer to this question is "yes" then please complete the next section regarding your participation in the elective. If your answer to this question is "no" then please skip ahead to the next topic.

Yes

No

Have you met with one or more medical students to advise them about a career in radiology?

If your answer to this question is "yes" then please complete the section regarding the mentorship you have provided. If your answer to this question is "no" then please skip ahead to the next topic.

Yes

No

Have you participated in direct medical student shadowing?

Yes

No

Have you prepared letters of recommendation for medical students in support of a residency application?

Yes

No

Have you directly participated in any research projects?

If your answer to this question is "yes" then please provide more information regarding your research efforts. If your answer to this question is "no" then please skip ahead to the next topic.

Yes

No

Have you been named as an author on any publications?

Yes

No

Please check all that apply

Peer-Reviewed Original Research

Peer-Reviewed Electronic Media/Web-Based Cases

Non Peer-Reviewed Publications

Book Chapter

Letters, Book Reviews, Lay Press

Other

Have you given any local, regional, national, or international presentations during the reporting period?

Yes

No

Please check all that apply

Lecture at a National/International Specialty or Interdisciplinary Meeting

Lecture at a Regional Specialty or Interdisciplinary Meeting

Lecture at a Local Interdisciplinary Meeting (non hospital-based)

Lecture for members of the general public

Abstract Presentation at a National/International Specialty or Interdisciplinary Meeting

Abstract Presentation at a Regional Specialty or Interdisciplinary Meeting

Poster Presentation at National/Regional/Local Meeting

Moderator at a National/International Specialty or Interdisciplinary Meeting

Moderator at a Regional/Local Specialty or Interdisciplinary Meeting

Other

Have you participated in any non-clinical CCP-based activities during this reporting period?

Yes

No

Please check all that apply

Management Activities

IT-Based Activities

Billing/Financial Activities

Other

Have you participated in any non-clinical hospital-based activities during this reporting period?

Yes

No

Please check all that apply

Medical Executive Committee

Quality Improvement Activities

Hospital-Based Tumor Boards

Hospital-Based IT Activities

Hospital-Based Equipment Review

Interdisciplinary Conferences

Graduate Medical Education Meetings

Other

Have you participated in specialty or society-based activities during this reporting period?

Yes

No

Please check all that apply

National/International Society Committee

Local/State/Regional Society Committee

Educational Meeting Coordinator

Manuscript Review for Peer-Reviewed Journal

Patient Outreach

Consulting

Other

Have you served as an advisor/mentor for a resident or resident(s) on a research project?

Yes

No