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Resident's Annual Report for
PEDIATRICS

Please submit within thirty (30) days of completion of the contract year.  Call (877) 231-ACOP with any questions.  Failure to meet the deadline for submission will result in delayed evaluation by the specialty college.

ALL FIELDS REQUIRED
   
Name of Resident:
AOA#:
Mailing Address:
Current Phone #
Training Institution:
Institution Address:
Name of Program Director:
Director Email Address:
Confirm Email Address:
Report Period: to
Medical School:
Year Graduated:
List Service Rotations for Report Period: PGY: 1 2 3 Other
   

 

Date of Service

Rotation Description

Populations Cared For
   

Adult

Peds

Mixed
         
Example: 1/1/06 - 3/1/06

Cardiology
         
        Start              End        

1.   –

2.   –

3.   –

4.   –

5.   –

6.   –

7.   –

8.   –

9.   –

10. –

11. –

12. –

13. –

1.      List areas of scholarly activity during this year of training (i.e., research, lectures, scientific papers).  Must list at least three activities. (See Article 4 Section H of Pediatric Basic Standards)

2.   Resident’s narrative evaluation of this year of training:  (50 word minimum required)

I certify that the information on this form is correct and accurate.

By checking this box contitutes as your signature.
By checking this box you verify that the resident has had the opportunity to review this report.

Date: / / (mm/dd/yyyy)