FLS Remote Testing Request Form

This form is for institutions wishing to schedule an FLS remote testing date for up to ten test candidates in a single day.

This form must be submitted at least three months prior to any requested dates. Once the form is received by SAGES and one of the requested dates is confirmed, an invoice will be generated and emailed to the contact person designated on the form. Invoices must be paid 30 days prior to the requested test date.

Once a test date is confirmed, the institution must follow the instructions in the confirmation email and adhere to the listed due dates for submission of information.
Program/Institution Name*
Billing Information (for invoice)
Street Address*
Address Line 2
City*
State/Province/Region*
Zip Postal Code*
Country*
Billing Contact Name*
Billing Contact Email*
Facilitator Information - (It is NOT recommended to have a physician act as a facilitator)
Facilitator Name**
*Must be someone who works in the skills lab and/or has had some experience with the FLS trainer box and laparoscopic instruments.
Facilitator Job Title*
Facilitator Job Description*
Facilitator Email*
Select your choice for the written test administration. ONLY CHOOSE ONE:*
- Option 1: Test takers will complete the written portion of the exam using the OLP testing service and will take the written test no sooner than seven (7) days prior to or later than seven (7) days following the date they take the skills test.
- Option 2: Test takers will complete the written portion of the exam on the same day they take the skills portion, utilizing an additional facilitator at your institution. Institution will provide computers and a separate, but close, room for administration of the written exam.
Facilitator 2 Name*
If you chose option #2 above, please complete the following information on the additional facilitator:
Facilitator 2 Job Title*
Facilitator 2 Job Description*
Facilitator 2 Email*
Remote Testing Information
Name of Person filling out this form (Main Contact)*
(liason for onsite testing at facility)
Main Contact Email*
Main contact Phone number*
Number of eligible FLS test candidates for one day of testing*
Preferred remote onsite testing date #1*
MM slash DD slash YYYY
Preferred remote onsite testing date #2*
MM slash DD slash YYYY
Preferred remote onstite testing date #3*
MM slash DD slash YYYY
Will you require an additional consecutive day of testing?*
Total number of additional test takers*
I understand that filling out this form does not guarantee a remote testing date. In the event that none of the preferred dates listed above are available, I understand the SAGES office will contact me directly to let me know and I may have to fill out an additional request form. I understand that failure to fill out this form correctly or completely may result in no response from the SAGES office. I understand that FLS Remote Testing is reserved for up to ten eligible test candidates prepared to take the FLS exam on the scheduled date.

All test dates I have listed above are accurate and will be accommodated by our facility if confirmed.
Signature

FLS Remote Testing Request Form

Billing Information (for invoice)

Facilitator Information - (It is NOT recommended to have a physician act as a facilitator)

Remote Testing Information

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