KSTAR Fitness for Duty Application Survey

Please note there is a $350 non-refundable application fee. You may pay online by posting this link into your browser https://tamu.estore.flywire.com/tamhsc---archi/kstar-application-fee-24564
or by mailing a check to KSTAR/RCHI at 2700 Earl Rudder Fwy S, Suite 3000, College Station, Texas, 77845

Physician information

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* 1. Name

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* 2. Email - this will be used to send you program information

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* 3. Phone number

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* 4. Address - we may use this to FedEx you information

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* 5. Date of Birth

Date of Birth

Date

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* 6. What is your gender?

Male

Female

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* 7. What country were you born in?

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* 8. What is your first language?

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* 9. What is your second language?

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* 10. About yourself

	Yes	No
Do you wear a hearing aid or have anything that assists with hearing?	Do you wear a hearing aid or have anything that assists with hearing? Yes	Do you wear a hearing aid or have anything that assists with hearing? No
Do you wear glasses, contacts, or have anything that assist with your vision?	Do you wear glasses, contacts, or have anything that assist with your vision? Yes	Do you wear glasses, contacts, or have anything that assist with your vision? No
Do you have any issues that prevent other people from understanding your speech?	Do you have any issues that prevent other people from understanding your speech? Yes	Do you have any issues that prevent other people from understanding your speech? No
Do you have any difficulties with walking, standing, or sitting for prolonged periods of time?	Do you have any difficulties with walking, standing, or sitting for prolonged periods of time? Yes	Do you have any difficulties with walking, standing, or sitting for prolonged periods of time? No
Do you use any device to help you with walking, standing, or sitting?	Do you use any device to help you with walking, standing, or sitting? Yes	Do you use any device to help you with walking, standing, or sitting? No
Do you have any issues with your fine motor skills?	Do you have any issues with your fine motor skills? Yes	Do you have any issues with your fine motor skills? No
Do you or does anyone else have a concern about your cognitive abilities?	Do you or does anyone else have a concern about your cognitive abilities? Yes	Do you or does anyone else have a concern about your cognitive abilities? No
Have you had a neuropsychological evaluation?	Have you had a neuropsychological evaluation? Yes	Have you had a neuropsychological evaluation? No
Have you been diagnosed with cognitive decline?	Have you been diagnosed with cognitive decline? Yes	Have you been diagnosed with cognitive decline? No
Do you or does anyone else have a concern about your mental health?	Do you or does anyone else have a concern about your mental health? Yes	Do you or does anyone else have a concern about your mental health? No
Have you had a neuropsychiatric evaluation?	Have you had a neuropsychiatric evaluation? Yes	Have you had a neuropsychiatric evaluation? No
Do you have a mental health diagnosis?	Do you have a mental health diagnosis? Yes	Do you have a mental health diagnosis? No
Do you have any issues that interfere with your ability to practice medicine?	Do you have any issues that interfere with your ability to practice medicine? Yes	Do you have any issues that interfere with your ability to practice medicine? No
Do you have any issues communicating with others?	Do you have any issues communicating with others? Yes	Do you have any issues communicating with others? No

if yes, please explain

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* 11. Are you currently enrolled in a Physician Health Program?

Yes

If yes, which one?