Fundamentals of Laparoscopic Surgery

...the definitive laparoscopic skills enhancement and assessment module.

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FLS Test Center Application Form

Institution Name*
Academic Affliate (if applicable)
Surgery ACGME# (if applicable)
Institution Street Address (where FLS testing would take place)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ACS Accredited Education Institute Level 1
ACS AEI Expiration date
MM slash DD slash YYYY
ACS Education Institute Level II
ACS AEI Expiration date
MM slash DD slash YYYY
Standard 1: Staff
FLS Champion
FLS Champion Information. Please attach current CV for FLS Champion to this application.
Name*
First Last
Job Title*
Department*
Email*
Phone*
Active SAGES member?*
- YES
- NO
Year of FLS Certification*
Role in Resident Education (please describe)*
Proctor Candidate #1
Please refer to Criterion 1.2 for proctor candidate requirements. Attach current CV for proctor candidate 1 to this application. *Each applicant test center may submit up to 3 (but no more than) proctor candidates for training.
Name*
First Last
Current job title*
Department*
Email*
Phone*
Brief job description (3-4 sentences)*
Proctors must dedicate 5% FTE to FLS related activities and should be familiar with laparoscopic equipment.*
- Select All
- Is able to dedicate 5% FTE to FLS related activities
- Is familiar with laparoscopic equipment
Proctor Candidate #2
Please refer to Criterion 1.2 for proctor candidate requirements. Attach current CV for proctor candidate 2 to this application. *Each applicant test center may submit up to 3 (but no more than) proctor candidates for training.
Name
First Last
Current job title
Department
Email
Phone
Brief job description (3-4 sentences)
Proctors must dedicate 5% FTE to FLS related activities and should be familiar with laparoscopic equipment.
- Select All
- Is able to dedicate 5% FTE to FLS related activities
- Is familiar with laparoscopic equipment
Proctor Candidate #3
Please refer to Criterion 1.2 for proctor candidate requirements. Attach current CV for proctor candidate 3 to this application. *Each applicant test center may submit up to 3 (but no more than) proctor candidates for training.
Name
First Last
Current job title
Department
Email
Phone
Brief job description (3-4 sentences)
Proctors must dedicate 5% FTE to FLS related activities and should be familiar with laparoscopic equipment.
- Select All
- Is able to dedicate 5% FTE to FLS related activities
- Is familiar with laparoscopic equipment
Standard 2: Equipment
Champion to complete this section.
Our Institution owns at least 2 FLS trainer boxes in working order with all necessary parts/accessories.*
- YES
- NO
Our institution has all of the following equipment for the sole purpose of FLS testing and training:*
• 2 laparoscopic needle drivers (non self-righting) • 1 laparoscopic locking grasper • 1 closed knot pusher • 1 open knot pusher • 2 Maryland dissectors • laparoscopic scissors (must keep enough on hand to replace them when they are dull) • 2 (10mm minimum) low profile trocars
- YES
- NO
Our institution has at least 2 monitors (1 for each trainer box) for sole use with the FLS trainer boxes that comply with the minimum standard.*
- YES
- NO
Our institution has at least 2 computers dedicated for FLS testing (please refer to the computer requirements document for more specific information).*
- YES
- NO
Our institution has dedicated space for FLS testing (please attach floor plan of space to be used for FLS Testing).*
- YES
- NO
Our Institution has the following supplies on hand as well as the ability to continue to acquire the following supplies:*
• FLS approved rubber penrose drains • 18” pre-tied ligating loops • FLS approved Single circle gauze sheets • FLS approved red foam organs • 2-0 silk (or sofsilk) suture at least 90cm in length on an SH or V-20 type needle • Disposable endoscopic scissors or scissor tips (1 new unit/ 10 testers on average)
- YES
- NO
Our institution understands that there are costs associated with administering the FLS exam and obtaining necessary supplies/equipment that the SAGES reimbursement rate per exam may not cover.*
- YES
- NO
Standard 3: Institutional Support
Please attach a letter from the medical school and/or hospital administration outlining their intent to support the staff time, funds, and space necessary to become and maintain FLS Test Center status.
For FLS Champion: I have read and understand the FLS Test Center Standards and Criteria document. I understand that if our institution does not meet or cannot comply with these standards for any reason, our application may be declined or our FLS Test Center deactivated. All of the information above is correct to the best of my knowledge and I have filled out this application as accurately as possible.*
I have read and understand the FLS Test Center Standards and Criteria document. I understand that if our institution does not meet or cannot comply with these standards for any reason, our application may be declined or our FLS Test Center deactivated. All of the information above is correct to the best of my knowledge and I have filled out this application as accurately as possible.
- YES
- NO
Champion's Full Name*
First Last
Champion's Title*
Submission Instructions
Payment for the application fee must accompany the completed application. Refer to the FLS Test Center fee schedule for the cost. If paying by credit card, please complete the form below. Instructions are also provided below for payment by check. Applications are reviewed by select members of the FLS committee and the FLS directors semi-annually (spring and fall). Applications submitted September 1-February 28 will be reviewed in the spring. Applications submitted March 1-August 31 will be reviewed in the fall. Notices regarding application approval, denial, or pending status will be emailed to the FLS champion at the email address provided on the application.
- Visa
- MasterCard
- Amex
Card Number
Expiration Date
MM slash DD slash YYYY
Security Code (3 digits on back of card, Amex: 4 digits on front of card)

3 digits on back of card, Amex: 4 digits on front of card
Cardholder Name
First Last
Payment must accompany application
- I have mailed a check made payable to SAGES
- I have mailed a money order to SAGES (for international orders)
Mail payment if paying by check to the following address (checks should be payable to SAGES; with ‘FLS’ in the memo field): SAGES Attn: FLS Program 11300 West Olympic Blvd Suite 600 Los Angeles, CA 90064
Champion CV*
Max. file size: 512 MB.
Proctor 1 CV*
Max. file size: 512 MB.
Proctor 2 CV
Max. file size: 512 MB.
Proctor 3 CV
Max. file size: 512 MB.
Floorplan of space to be used for FLS Testing*
Max. file size: 512 MB.
Letter from the medical school and/or hospital administration outlining their intent to support the staff time, funds, and space necessary to become and maintain FLS Test Center status.*
Max. file size: 512 MB.
Please attach a letter from the medical school and/or hospital administration outlining their intent to support the staff time, funds, and space necessary to become and maintain FLS Test Center status.

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