FLS Online Checklist Please note: This Form must be received at least 3 weeks prior to your confirmed test date(s). Test dates are subject to cancellation if the completed checklist is not submitted at least 3 weeks in advance. Section 1: Program InformationPlease provide the requested program information below.Program Name:* Test Location Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Test Dates:* Program Contact (Person Filling Out This Form):* *The designated contact must be able to greet the FLS proctor and be available during testingEmail* Day of testing contact phone (in case of any urgent/last minute issues):*Number of scheduled test takers:*Select One8910111213141516171819202122232425Section 2: ChecklistPlease check all of the following:Please confirm that all of the following items have been completed:* Our program has at least 8 confirmed test takers scheduled on the onsite testing date. We have purchased and assigned a test voucher for each scheduled test taker. All assigned test vouchers are valid (i.e. not previously used and have not expired). Each scheduled test-taker will create a test-taker account in Webassessor (or one will be created for them) using the directions provided prior to the test date. Our FLS Trainer box is in good working condition and will be set-up appropriately with a monitor on the test date. ALL of the following FLS accessories will be on hand for the test date: peg transfer board w/6 objects, jumbo clip, red foam suture block. ALL of the following instrumentation has been obtained and will be available on the test date: AT LEAST 2 Maryland Dissectors, 1 locking Grasper, 1 pair of (sharp) endoscopic scissors, 2 needle drivers, 2 trocars, 1 Knot pusher (open or closed). ALL test-takers have been made aware of the onsite testing date and been given plenty of opportunities to prepare for the exam using the FLS trainer box and instrumentation/supplies. ALL test-takers have been provided with the appropriate FLS exam information, including the FLS Manual Skills Proficiency Curriculum document. Rooms have been reserved all day for the FLS testing in which no other activities are taking place. 'Testing in Progress' signs will be posted to minimize noise and disruptions during testing At least 3 computers will be set-up in the testing area for the written portion of the exam. Please note: the computer testing areas should be separated from the skills testing area (FLS trainer box) to minimize disruptions to test takers. The testing rooms/areas must be in close proximity of one another and the FLS liaison from the requesting institution must be available to monitor the computer testing area for the duration of testing. The computers that will be used for testing meet the minimum requirements as stated on the FLS Testing Computer Requirements document (PC, high speed internet, Internet Explorer browser) I understand our program must meet all of the requirements and guidelines set forth in the Requirements for Onsite Testing document. I understand that failure to provide any of the appropriate testing materials or meet the standard guidelines may result in cancellation of the testing or an additional test fee All boxes must be checked in order to properly submit this form. Please attach specific instructions or maps for the FLS proctor’s use upon arriving at the institution using the button below. PLEASE NOTE: The FLS proctor will arrive at the institution approximately 30 minutes prior to first scheduled exam. The proctor will contact the designated contact listed above if he/she has any questions or issues upon arrival.*Accepted file types: pdf, doc, docx, xls, jpg, gif, png, Max. file size: 512 MB. You have not completed the above check list. Please confirm that all check boxes have been checked in order to proceed. The SUBMIT button will not work unless the entire list has been checked. By clicking the button below, I am certifying that all the above information is correct. I understand that if my facility must cancel within 3 weeks of the scheduled test date, our facility will be charged a penalty of $500.00CommentsThis field is for validation purposes and should be left unchanged.