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* 1. Age

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* 2. Which of the following best describes your practice model?

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* 3. How many years have you been in practice since completing residency or fellowship?

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* 4. How many years practicing bariatric surgery? Type years in text box.

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* 5. What is your employment status?

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* 6. What percentage of your time is dedicated to bariatric surgery?

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* 7. What is your career volume for bariatric surgery?

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* 8. In what state are you employed?

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* 9. Did you complete a Fellowship?

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* 10. If yes to the above question, what type? (MIS, MIS with bariatrics/bariatric only) Other (Surgical oncology, vascular, GI, Hepato-Billary)

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* 11. Select the method that most accurately reflects your current compensation model?

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* 12. What is the amount of your total compensation, including salary, bonus and/or incentive payments, research stipends, honoraria and medical directorship fees? (state the amount reported as direct compensation on Form W-2 and Form 1099)

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* 13. What is your estimate annual retirement contribution? (Report all contributions to retirement plans including defined benefit and defined contribution plans.)

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* 14. What of the following benefits are provided to you and paid by your employer?

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* 15. Do you receive a bonus or incentive?

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* 16. If you receive a bonus or incentive, is it based upon RVU target?

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* 17. If you receive a bonus or incentive, is the bonus based upon Medical Directorship?

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* 18. If you receive a bonus or incentive through a Quality Metric? (select all that apply)

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* 19. If your compensation is based on WRVU production, provide the amount per WRVU.

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* 20. If your incentive is based upon WRVU production, provide the threshold amount at which the incentive begins and the compensation amount per WRVU that you receive. (For example, you must produce 10,000 WRVU’s before incentive compensation begins. Once you reach 10,000 WRVU’s, you are compensated (X) amount for each WRVU above that threshold.)

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* 21. How many work RVUs did you produce?

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* 22. How many days a month do you take call?

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* 23. Are you paid for taking call?

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* 24. How many TOTAL operative procedures did you perform in 2012 (include ALL procedures including non-bariatric procedures)?

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