old-Reference by Master Instructor for
Exception to IP Certification application

You must be a CPoCUS Master Instructor to use this form.
Asterisk denotes required answer.

Question Title

* 1. Please enter today's date.

Select the date below:

Date

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* 2. Please enter your name.

Question Title

* 3. Please enter your IP number.

Question Title

* 4. Please select the track in which you are a Master Instructor (MI) (check all that apply).

AC CORE MI

FM CORE MI

RESUS MI

DIAG MI

MSK MI

UPVA MI

Other

Question Title

* 5. Please enter the name of the Exception to IP Certification candidate.

Question Title

* 6. Please select which track the Exceptions candidate has applied for (check all that apply).

AC CORE IP

FM CORE IP

RESUS IP

DIAG IP

MSK IP

UPVA IP

UPVA MI

Question Title

* 7. Please indicate how long you have known the Exceptions candidate.

1-2 years

3-5 years

6-10 years

11+ years

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* 8. Please indicate the Exceptions candidate's ultrasound teaching experience (check all that apply).

The Exceptions candidate is comfortable teaching the content and required scans relevant to their Exceptions application

The Exceptions candidate can reliably administer the IP exams relevant to their Exceptions application

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* 9. Additional comments regarding the Exceptions candidate (optional).

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* 10. Additional material (optional).

Please label your file with your full name

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old-Reference by Master Instructor for Exception to IP Certification application

Question Title

* 1. Please enter today's date.

Question Title

* 2. Please enter your name.

Question Title

* 3. Please enter your IP number.

Question Title

* 4. Please select the track in which you are a Master Instructor (MI) (check all that apply).

Question Title

* 5. Please enter the name of the Exception to IP Certification candidate.

Question Title

* 6. Please select which track the Exceptions candidate has applied for (check all that apply).

Question Title

* 7. Please indicate how long you have known the Exceptions candidate.

Question Title

* 8. Please indicate the Exceptions candidate's ultrasound teaching experience (check all that apply).

Question Title

* 9. Additional comments regarding the Exceptions candidate (optional).

Question Title

* 10. Additional material (optional).

old-Reference by Master Instructor for
Exception to IP Certification application