Surname

First Name

Preferred Name (if different to first name)

Date of Birth

Email Address

Which hospital do you work in?

Do you have any existing companionships or partnerships with surgeons and/or institutions in low- and middle-income countries? Do you have any existing companionships or partnerships with surgeons and/or institutions in low- and middle-income countries? Yes No

If yes, please provide details

Do you have any previous experience working in low- and middle-income countries? Do you have any previous experience working in low- and middle-income countries? Yes No

If yes, please provide details

Are you a vascular surgeon practicing in an established vascular unit and would like to participate in Global Vascular Companionship? Are you a vascular surgeon practicing in an established vascular unit and would like to participate in Global Vascular Companionship? Yes No

What are the specific and overall goals you wish to achieve by participating in the GVC program? Please provide a detailed response.

What are the most common vascular surgical conditions in your region? e.g. PVD, diabetic foot infection, venous insufficiency/ulceration

In what way would you participate in the Global Vascular Companionship? In what way would you participate in the Global Vascular Companionship? Hosting a trainee from a developing vascular unit Funding a trainee to receive training at another unit Providing education, mentorship and/or proctorship Visiting a developing unit to provide training Capacity building for vascular surgical services

In which country are you located?

Which countries or regions would you most like to work with as a mentor in this program?

What is/are your preferred languages?

What languages do your patients speak?

What language is used for your written medical notes?

What international language(s) do your staff speak?

If selected as a mentor, would you have capacity to travel to the country of your mentee to provide in-person training for a short mission of one to two weeks within the next two years? If selected as a mentor, would you have capacity to travel to the country of your mentee to provide in-person training for a short mission of one to two weeks within the next two years? Yes No

Would you have access to funds or grants to support this trip? Would you have access to funds or grants to support this trip? Yes No

Do you have any capacity for a post fellowship training position at your institution for your mentee? Do you have any capacity for a post fellowship training position at your institution for your mentee? Yes No

If yes, please provide details

Could you tell us a little bit about the vascular surgery training program in your country?

What is the size of the catchment population served by your hospital? What is the size of the catchment population served by your hospital? *Less than 100,000Between 100,000 and 500,000Between 500,000 and 1,000,000More than 1,000,000Unsure

Is your hospital affiliated with a university? Is your hospital affiliated with a university? Yes No

If yes, please specify

How many beds does your hospital have? How many beds does your hospital have? *Less than 100Between 100 and 200Between 200 and 300Between 300 and 400Between 400 and 500More than 500Unsure

How many vascular surgeons practice in your unit? How many vascular surgeons practice in your unit? *Less than 55 to 10More than 10

Which of the following vascular surgeries are performed at your hospital? (tick all that apply) Which of the following vascular surgeries are performed at your hospital? (tick all that apply) Arteriovenous fistula creation for renal access Bowel resection and anastomosis Carotid endarterectomy Diabetic/high-risk foot surgery Femoral endarterectomy Femoral thrombectomy Femoral popliteal bypass Femoral tibial bypass Lower limb angiogram and angioplasty Major limb amputations Minor limb amputations Open abdominal aortic aneurysm repair Tunnelled cuffed central venous catheter for renal access

Major Limb Amputations (if yes, please indicate how many)

Do you offer haemodialysis? Do you offer haemodialysis? Yes No

Do you have high-risk foot service? Do you have high-risk foot service? Yes No

Do you have access to any of the following professionals? (tick all that apply) Do you have access to any of the following professionals? (tick all that apply) Podiatrist Orthotist Dietitian Wound Nurse

Do you have any experience working in low- and middle-income countries? Do you have any experience working in low- and middle-income countries? Yes No

Does your unit currently offer, or is it considering offering, a training post (vascular surgery resident/registrar) on an established pathway to becoming a vascular surgeon in your country? Does your unit currently offer, or is it considering offering, a training post (vascular surgery resident/registrar) on an established pathway to becoming a vascular surgeon in your country? Yes No

Please provide us with any further information that you would like us to know

Upload your CV here File InputChoose FilesNo Files ChosenAccepted file types: jpg, jpeg, jpe, mka, pdf, 7z, xla, xls, xlt, xlw, xltx. Max. file size: 4 MB