Thank you for your interest in the ACS Certificate in Applied Surgical Education Leadership. Information about the 2022-23 program can be found on the CASEL website. The deadline to apply has been extended to June 24, 2022.

Accepted participants will be notified in July 2022. For those selected, the in-person CASEL Kick-Off will be held on October 6 - 8, 2022 at the American College of Surgeons in Chicago, IL. The program will continue for 6 - 8 weeks with supplemental online programming (offered on scheduled evenings).

Questions about the program or the application process may be sent to acscasel@facs.org.

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* 1. First Name:

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* 2. Last Name:

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* 3. Contact Information:

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* 4. Surgical Specialty:

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* 5. Number of Years in Surgical Practice:

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* 6. The 2022-23 CASEL program will begin with a 3-day in-person Kick-Off from Thursday October 6, 2022 - Saturday October 8, 2022 at the American College of Surgeons in Chicago, IL. This will be followed by 6-8 additional 1.5 hour lectures that will be held on weekday evenings via Zoom between October, 2022 - March, 2023.

Applicant must indicate their commitment to participating in these events - please check all statements that apply:

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* 7. Describe current and past education/surgical leadership roles (for each role held, indicate the number of years' experience):

  1-2 Years 3-5 Years 5-10 Years 10+ Years N/A (Have not held)
GME Program Director
Associate GME Program Director
Core Faculty
Clerkship Director
Associate Clerkship Director
Vice/Associate Chair, Surgery Dept
Associate Dean
Assistant Dean
Simulation Center Director
DIO (Designated Institutional Official)

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* 8. Have you attended the ACS Surgeons as Educators Course? If "yes" is selected, please indicate the year of participation:

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* 9. List formal training in surgical or medical education (list relevant courses/programs other than the ACS Surgeons as Educators Course). Examples include: ASE SERF program, Macy course, Masters Degree.

Applicant may list N/A if they have had no previous formal surgical or medical education training.

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* 10. Provide a brief statement of two or three career goals:

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* 11. Provide a brief statement describing what you hope to gain professionally and personally from participating in ACS CASEL. Please limit responses to 250 words.

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* 12. Upload a current curriculum vitae (CV):

PDF, DOC, DOCX file types only.
Choose File

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* 13. A key component of CASEL is the implementation of a surgical education leadership project at each participants' home institution. Briefly outline one to two proposals for a surgical education leadership project you are interested in developing and implementing at your home institution over the course of the year-long CASEL program.

Please reference the CASEL program website for project examples. A good proposal includes 4 elements: a sentence stating the problem/gap, a plan for how you can address the problem/gap, possible methods for measuring success of the intervention, and a brief description of what educational leadership qualities the project will call upon. Please limit each response to 250 words.

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* 14. Provide the name and contact information of a department chair or organization supervisor. To succeed with a CASEL project, each applicant must be supported by their institution. As your application is under consideration, we may reach out to the contact listed to provide a letter of support.

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* 15. (Optional) Applicant may provide additional information that was not previously discussed as part of the application:

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