Name of Resident AOA # Mailing Address

AMERICAN OSTEOPATHIC ASSOCIATION RESIDENT S ANNUAL REPORT FOR GENERAL SURGERY and/or SPECIALTY TRACK INTERNSHIP American Osteopathic College of Otolaryngology-Head and Neck Surgery Name of Resident AOA # Mailing Address Daytime Phone ( ) Email Base Training Institution Address Name of Program Director(s) Year of Training: General Surgery Specialty Track Intern Report Period: From To: mo/day/yr mo/day/yr List hospital(s), length of each rotation, and identify rotation (as it applies to the specialty track intern): A. Name of Hospital Length of Rotation Rotation B. Name of Hospital Length of Rotation Rotation C. Name of Hospital Length of Rotation Rotation D. Name of Hospital Length of Rotation Rotation E. Name of Hospital Length of Rotation Rotation You are requested to use the above listing(s) as a way to identify the location of the facility in which each procedure was performed. Use the letter of the facility from above along with the number of procedures as you fill out each area of the segregated totals (i.e., b-3, c-5, etc.) Thus, one would be able to see how many procedures of each type are done in the base or an outside hospital. Total # of Major Procedures First Assistant Performed Under Supervision Total # of Minor Procedures First Assistant Performed Under Supervision Total Surgical Mortalities INSTRUCTIONS: This form is used by AOA-approved hospitals with residency programs in Otolaryngology and/or Facial Plastic Surgery and/or Head and Neck Surgery and by residents in the completion of their required annual reports. For your convenience, this form is compatible with the codes and nomenclature found in the International Classification of Diseases (ICD), 9 th Edition, which is used by medical record administrators. Please complete the entire form within thirty (30) days of the completion of EACH TRAINING YEAR and forward to the appropriate office as indicated below. One copy of this report with supporting documentation are to be mailed to the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery (AOCOO-HNS), 4764 Fishburg Road, Suite F, Huber Heights, OH 45424 within thirty (30) days of completion of each contract year. Failure to meet the deadline for submission may result in delayed evaluation by the specialty college. I certify that the information on this form is correct and accurate. (Signature of Resident) (Date) (Signature of Program Director) (Date)

Resident's Annual Segregated Total Report for General Surgery / Specialty Track Internship Number of Procedures I. Operations on Thyroid & Parathyroid Glands A. Unilateral thyroid lobectomy 06.2 60220 B. Other partial thyroidectomy 06.3-06.39 60200 C. Total thyroidectomy 06.4 60240 D. Excision of thyroglossal duct 06.7 60280 E. Parathyroidectomy 06.81-06.89 60500 F. Other operations thyroid &parathyroid 06.91-06.99 region TOTAL PROCEDURES FOR SECTION I II. Operations on Other Endocrine Glands A. Adrenalectomy 07.3 60540 B. Thymectomy 07.80-07.82 60520 TOTAL PROCEDURES FOR SECTION II III. Operations on Liver A. Hepatotomy (Other than needle biopsy) 50.0 47010 B. Wedge resection 50.22 47100 C. Lobectomy 50.3 47125 D. Repair of liver 50.61-50.69 47350-60 TOTAL PROCEDURES FOR SECTION III IV. Operations on Gallbladder and Biliary Tract A. Cholecystostomy 51.01-51.04 47480 B. Laparoscopic Cholecystectomy 54.21-51.22 49310 C. Open Cholecystectomy 51.21-51.22 47600 Secondary procedures Common duct exploration 51.51 Operative cholangiogram 87.53 Without stones Choledochoscopy 51.11 D. Gall bladder or bile duct anastomosis 51.3 47720 E. Common duct exploration 51.41-51.49 47420 F. Sphncteroplasty 51.83 47460 TOTAL PROCEDURES FOR SECTION IV V. Operations on Pancreas A. Pancreatotomy(other than needle biopsy) 52.01-52.09 B. Local excision of pancreatic lesion 52.2 48100 C. Marsupialization of pancreatic cyst 52.3 48500 D. Internal drainage of pancreatic cyst 52.4 48520 E. Partial Pancreatectomy 52.51-52.59 48140 F. Total pancreatectomy 52.6 48155 G. Radical pancreaticoduodenectomy 52.7 48150 TOTAL PROCEDURES FOR SECTION V Page 2 - COPT/R-99

VI. Repair of Hernia A. Inguinal-unilateral 53.00-53.05 49500-49502 B. Inguinal-bilateral 53.10-53.17 49503-49509 C. Femoral Hernia 53.21-53.29 49550-49551 D. Umbilical Hernia 53.41-53.49 49553-49554 E. Incisional Hernia 53.51-53.59 49560 F. Other (list separately) 53.9 TOTAL PROCEDURES FOR SECTION VI VII. Other abdominal operations (only as Primary procedures) A. Exploratory laparotomy 54.11 49000 B. Lysis of adhesions (For relief of obstruction) 54.5 44005 C. Closure of disruption 54.61 49900 D. Peritoneovenous fistula 54.94 49425 TOTAL PROCEDURES FOR SECTION VII VIII. Operations on Kidney A. Nephrostomy 55.01-55.04 Open 50040 Percutaneous 50041 B. Percutaneous Nephrolithotomy 55.01 50080 C. Extracorporeal Lithotripsy 98.51 50540 D. Open Biopsy 55.31-55.39 50205 E. Partial nephrectomy 55.4 50240 F. Total nephrectomy (including Radical) 55.51-55.54 50220 G. Pyeloplasty 55.87 50100 TOTAL PROCEDURES FOR SECTION VIII IX. Operations on Ureter A. Removal of obstruction-transurethral 56.0 52214 B. Ureteral meatotomy 56.1 50605 C. Ureterotomy 56.2 50600 D. Ileal conduit 56.51-56.52 50820 E. Other external diversion 56.61-56.62 50860 F. Other anastomosis 56.71-56.79 50810 G. Repair of ureter 56.81-56.89 50900 TOTAL PROCEDURES FOR SECTION IX Page 3 - COPT/R-99

X. Operations on Urinary Bladder A. Cystotomy (other than Percutaneous insertion) 57.11-57.19 51045 B. Cystostomy 57.21-57.22 51040 C. Excision or fulguration 57.41-57.49 52234 D. Partial cystectomy 57.6 51565 TUR Open E. Total cystectomy 57.71-57.79 51570 F. Repair of bladder rent 57.81 51860 TOTAL PROCEDURES FOR SECTION X XI. Other Operations on Urinary Bladder A. Plication of urethrovesical junction 59.3 51800 B. Urethral suspension MMK 59.5 51840 C. Other repair of stress incontinence 59.71-56.79 51841 TOTAL PROCEDURES FOR SECTION XI XII. Operations on Prostate and Seminal Vesicles A. Transurethral resection 60.2 52601 B. Prostatectomy 60.3 55801 Suprapubic Retropubic Perineal C. Radical prostatectomy 60.5 55810 D. Vasovasostomy 63.82 or 60.71-60.79 55400 TOTAL PROCEDURES FOR SECTION XII XIII. Operations on Testes A. Incision of testis 62.0 54510 B. Unilateral orchiectomy 62.3 54520 C. Bilateral orchiectomy 62.41-62.42 54520-50 D. Orchiopexy 62.5 54640 TOTAL PROCEDURES FOR SECTION XIII XIV. Operations on Ovary ONLY AS PRIMARY PROCEDURE A. Wedge resection 65.2 58920 B. Unilateral oophorectomy 65.3 58940 C. Unilateral salpingo-oophorectomy 65.4 58720 D. Bilateral oophorectomy 65.51-65.52 58940-50 E. Bilateral salpingo-oophorectomy 65.61-65.62 58720-50 F. Repair of ovary 65.71-65.79 TOTAL PROCEDURES FOR SECTION XIV Page 4 - COPT/R-99

XV. Operations on Fallopian Tubes ONLY AS PRIMARY PROCEDURE A. Bilateral endoscopic occlusion of tubes 66.21-66.29 58982 B. Other bilateral ligation and division 66.31-66.39 58600 C. Bilateral salpingectomy 66.51-66.52 58701 D. Salpingoplasty 66.79 58750 TOTAL PROCEDURES FOR SECTION XV XVI. Operations on Uterus A. Hysterotomy (including cesarean section) 68.0 59510 B. Total abdominal hysterectomy 68.4 58150 C. Vaginal hysterectomy 68.5 58260 D. Radical hysterectomy with node sampling or bilateral lymphadenectomy 68.6 58200 E. Pelvic Exenteration 68.8 58240 Anterior Posterior Total TOTAL PROCEDURES FOR SECTION XVI XVII. Operations of Vagina and cul-de-sac A. Obliteration or total excision of vagina 70.4 57120 B. Repair of cystocele and rectocele 70.50-70.52 57291 C. Repair of enterocele 70.8 57268 D. Vaginal reconstruction 70.61-70.62 57291 TOTAL PROCEDURES FOR SECTION XVII XVIII. Operations on Breast A. Reduction mammoplasty or subcutaneous mammectomy 85.31-85.36 19318 B. Mastectomy 85.4 1. Quandrantectomy 85.23 19162 2. Unilateral simple 85.41 19140 3. Bilateral simple 85.42 19140-50 4. Unilateral modified radical 85.43 19240 5. Bilateral modified radical 85.44 19240-50 6. Unilateral standard radical 85.45 19200 7. Bilateral standard radical 85.46 19200-50 8. Unilateral extended radical 85.47 19220 9. Bilateral extended radical 85.48 19220-50 C. Augmentation mammoplasty 85.50-85.54 19324 D. Mastopexy 85.6 19316 E. Total reconstruction of breast 85.7 19360 TOTAL PROCEDURES FOR SECTION XVIII Page 5 - COPT/R-99

XIX. Neurological Surgery A. Burr hole exploration 01.11-01.19 61106 for ICP or Reservoir placement Ventriculostomy B. Craniotomy 01.21-01.25 61304 for Cerebral aneurysm or AVM Brain Tumor Cerebral revascularization Elevation depressed skull fracture Decompression for Tic Seizure ablation C. Incision of brain 01.31-01.39 61500 D. Rhizotomy 03.1 61500 E. Cordotomy 03.21-03.39 63194 Open Percutaneous F. Laminectomy 80.51 63000 1. Cervical 80.51 2. Thoracic 80.51 3. Lumbar 80.51 G. Repair of peripheral nerve (other than carpal tunnel) 04.71-04.79 64830 H. Ventricular shunt 02.31-02.39 62910 I. Operations on cranial nerves 04.01-04.99 612460 J. Sympathectomy 05.2 61460 1. Cervical 05.22 2. Thoracic 05.23 3. Lumbar 05.23 K. Carotid endarterectomy 35301 L. Anterior cervical disectomy 80.51 63075 M. Other (list separately, refer to page 10) TOTAL PROCEDURES FOR SECTION XIX XX. Thoracic Surgery: Lung and Bronchus A. Segmental resection lung 32.3 32500 B. Lobectomy (total or segmental) 32.4 32480 C. Pneumonectomy (simple or radical) 32.5 32440 D. Radical pneumonectomy with intra pericardial dissection 32.6 32441 E. Repair of bronchial tear 33.41 32815 F. Resection of mediastinal tumor 34.3 39220 G. Exploratory thoracotomy 34.02 32100 Biopsy Bleb resection Pleurodesis Drainage Trauma 32110 Page 6 - COPT/R-99

XX. Thoracic Surgery: Long and Bronchus (continued) H. Correction major thoracic deformity (trauma) 34.21-34.29 32820 I. Decortication of lung 34.51 32320 TOTAL PROCEDURES FOR SECTION XX XXI. Cardiovascular Surgery A. Replacement of heart valve 35.20-35.28 33430 B. Repair of septal defect 35.50-35.54 33641 C. Total repair congenital cardiac 35.81-35.83 33785 anomalies D. Coronary artery bypass 36.10-36.19 33510 IMA Vein With angioplasty E. Pericardiotomy with drainage 37.12 33020 F. Repair of trauma to heart & pericardium 37.4 33305 G. Permanent transvenous pacemaker 37.74 33206 H. Intra aortic balloon pump insertion 37.61 33970 I. Others (list separately, refer to page 10) TOTAL PROCEDURES FOR SECTION XXI XXII. Vascular Surgery A. Embolectomy or thrombectomy (limb) 38.0 34000 B. Endarterectomy 38.0 35000 Carotid Aortic Iliac or Femoral C. Ligation and stripping varicose veins 38.50-38.59 37720 D. Interruption of inf. Vana cava 38.7 37620 Transvenous Ligation or clip E. Intra-abdominal venous shunt 39.1 35531 F. Intra-thoracic vascular graft 39.23 35626 G. Aorto-iliac-femoral graft 39.25 35640 H. Peripheral vascular graft 39.29 35656 Hip to Knee Knee to foot Hip to foot I. Suture of artery 39.31 35200 J. Abdominal aortic resection with graft 38.46 35081 K. All other aneurysm resections 38.40-38.49 35100 L. Arteriovenous fistula for dialysis 39.27 36820 M. Arteriovenous shunt (dialysis) 39.29 36821 N. Percutaneous angioplasty (independent procedure) 39.30-39.32 35450 O. Sympathectomy (see Neurologic Surg.) 05.21-05.29 Page 7 - COPT/R-99

XXII. Vascular Surgery (continued) P. Major amputation (see Orthopedic Surg.) (no digits) 84 Q. Other (list separately, refer to page 10) TOTAL PROCEDURES FOR SECTION XXII XXIII. Orthopedic Surgery A. Major amputations of limbs 84.00-84.19 27450 B. Arthroplasties of major joints 81.00-81.87 27442 C. Open reduction of major bones or joints 79.80-79.89 27506 D. Other (list separately, refer to page 10) TOTAL PROCEDURES FOR SECTION XXIII XXIV. Operations on the Digestive System A. Operations on esophagus 1. Esophagotomy 42.01-42.09 43000 2. Cervical esophagostomy 42.10-42.19 43352 3. Excision of diverticulum with or without myotomy 42.31-42.39 43130 4. Partial esophagectomy 42.41 43110 5. Total esophagectomy 42.42 43110 6. Esophagomyotomy 42.7 43330 7. Repair of Esophagus 42.81-42.89 43410 B. Operations on stomach 1. Temporary gastrostomy 43.1 Laparotomy PEG 43750 2. Permanent Gastrostomy 43.2 43832 3. Pyloromyotomy 43.3 43520 4. Partial gastrectomy with anastomosis to esophagus 43.5 43638 5. Partial gastrectomy-bilroth I 43.6 43630 6. Partial gastrectomy-bilroth II 43.7 43631 7. Total gastrectomy 43.91-43.99 43620 8. Vagotomy 44.00-44.03 With pyloroplasty 44.21-44.29 43640 With gastrojejunostomy 44.39 43642 With pyloric antrectomy 43.6 43643 Transthoracic 64752 Highly selective 43641 9. Gastric bypass or stapling (any method) 44.31 43844 10. Suture of perforated ulcer (gastric or duodenal) 44.40-44.42 43840 11. Closure of gastrostomy 44.62 43870 Page 8 - COPT/R-99

XXIV. Operations on the Digestive System (continued) Operations on stomach (continued) 12. Creation of esophagogastric sphincteric competency 44.66 Transabdominal 39502 Transthoracic 39520 13. Repair of diaphragmatic hernia (Traumatic) 53.7 39540 14. Other (list separately,refer page10) 44.99 TOTAL PROCEDURES FOR SECTION XXIV XXV. Incision Excision and Anastomosis of Intestine A. Enterotomy 45.00-45.03 44020 B. Enterorrhaphy Large intestive 46.75 44601 Small intestine 46.73 44600 C. Enteroenterostomy 46.20-46.24 44130 D. Partial small bowel resection 45.62 44120 E. Resection of cecum and terminal ileum 45.72 44160 F. Right hemicolectomy 45.73 44140 G. Resection of transverse colon 45.74 44142 H. Left hemicolectomy 45.75 44145 I. Sigmoid resection 45.76 44146 J. Total abdominal colectomy (subtotal colectomy) 45.8 44160 K. Proctocolectomy 48.41 44155 L. Proctosigmoidectomy (low anterior resection) 48.79 44147 M. Abdominoperineal resection 48.5 45110 N. Colostomy (primary operation) 46.10-46.13 44320 O. Closure of stoma or fistula 46.52 44620 P. Appendectomy(primary proced.only) 46.10-46.13 44950 TOTAL PROCEDURES FOR SECTION XXV XXVI. Operations on Spleen A. Elective splenectomy 41.5 38111 B. Splenectomy for trauma 41.5 38110 C. Splenorrhaphy 41.95 38115 TOTAL PROCEDURES FOR SECTION XXVI Page 9 - COPT/R-99

OTHER MAJOR SURGERIES Number of Procedures TOTAL OTHER MAJOR PROCEDURES Page 10 - COPT/R-99

SUMMARY OF PROCEDURAL SECTIONS A. Total Procedures for Section I B. Total Procedures for Section II C. Total Procedures for Section III D. Total Procedures for Section IV E. Total Procedures for Section V F. Total Procedures for Section VI G. Total Procedures for Section VII H. Total Procedures for Section VIII I. Total Procedures for Section IX J. Total Procedures for Section X K. Total Procedures for Section XI L. Total Procedures for Section XII M. Total Procedures for Section XIII H. Total Procedures for Section XIV O. Total Procedures for Section XV P. Total Procedures for Section XVI Q. Total Procedures for Section XVII R. Total Procedures for Section XVIII S. Total Procedures for Section XIX T. Total Procedures for Section XX U. Total Procedures for Section XXI V. Total Procedures for Section XXII W. Total Procedures for Section XXIII X. Total Procedures for Section XXIV Y. Total Procedures for Section XXV Z. Total Procedures for Section XXVI Total Other Major Procedures OVERALL TOTAL OF PROCEDURES Number of Procedures Page 11 - COPT/R-99

NUTRITIONAL SUPPORT SERVICE A. Nutritional Support Cases 1. Enteral Support 2. Peripheral Support 99.15 3. Central Support B. Nutritional Support Techniques 1. Central venous access a. Insertion into a vein 38.93 36489 Subclavian Internal Jugular b. Cutdown 38.94 c. Broviac/Hickman Catheter insertion 36494 d. Mediport Infusoport 86.07 36495 e. Other Total of Nutritional Support Service ENDOSCOPY A. Esophagogastroduodenoscopy 45.13 43235 B. Rigid Sigmoidoscopy 45.24 45238 C. Flexible Sigmoidoscopy 45.24 45330 D. Fiber optic Colonoscopy 45.23 45378 E. Fiber optic Bronchoscopy 33.22 31625 1. With biopsy 33.24 31625 F. Cystoscopy 57.32 52000 G. Peritoneoscopy 54.21 49300 H. E.R.C.P. 1. Cannulation ob biliary tract 51.97 2. Or pancreatic duct 52.91 43260 3. With sphincterotomy 43262 4. Choledochoscopy 51.11 47550 Total of Endoscopic Procedures Page 12 - COPT/R-99

MINOR SURGERIES Basic principles of wound care Opening of abdomen 54.19 49000 Closing of abdomen 54.63 49001 Excision of skin lesions Benign 11200-00 Malignant 11600-11646 Excision of subcutaneous lesions 86.3 11400-71 Repair of laceration 86.49 Simple 12001-18 Complicated 12031-152 Critical care monitoring Placement of arterial line 38.91 36620 Placement of central venous line 38.93 36489 Placement of Swan-Ganz catheter 89.64 93503 Enteral support Placement of nasojejunal feeding tube 96.6 43755 Percutaneous endoscopic gastrostomy 43.11 43750 Permanent gastrostomy 43.19 43832 Jejunostomy Needle 46.32 44015 Tube 46.39 44016 Placement of Infusaport 86.06 36493 Placement of Hickman/Broviak Groshong catheter 38.94 36494 Implantable venous access device 86.07 36495 Excision of lymph node (biopsy) 40.11 38500 Needle liver biopsy 50.11 47000 Needle aspiration of thyroid 06.01 60100 Anus Fissurectomy 49.39 46270 Fistulectomy 49.12 44600 Drainage of perianal abscess 49.93 46050 Pilonidal cystectomy 86.21 10080-81 Hemorrhoidectomy Injection therapy 49.42 46500 Rubber banding 49.45 46221 Infra-red coagulation 49.44 46222 Cryosurgery 46.44 46223 Laser 46224 Surgical Excision 49.46 46255 Breast Drainage of abscess 85.0 19020 Excision of recurring suppuration 19112 Aspiration/needle biopsy 85.11 19100 Excision of breast mass 85.21 19120 Page 13 - COPT/R-99

MINOR SURGERIES (continued) Vulva Local excision of lesion 71.3 56600 Drainage of Bartholin cyst 71.22 56420 Excision of Bartholin cyst 71.24 56740 Vagina Repair of laceration [OB 75.69] 70.71 57200 Excision of vaginal lesion 70.33 57100 Cervix Colposcopy 70.21 57452 Conization 67.2 57520 Repair of cerical laceration [OB 75.51] 67.61 57720 Uterus Fractional dilatation and curettage 69.09 58120 Endometrial biopsy 68.16 58100 Fallopian Tubes Sterilization procedure 1. Open 66.39 58600 2. Laparoscopic 66.29 58982 Trauma Thoracentesis 34.91 32000 Closed tube thoracostomy 34.04 32020 Pericardiocentesis 37.0 33010 Endotracheal intubation 96.04 31500 Ventilator support 93.92 94656 Abdominal paracentesis 54.91 49082 with lavage 54.98 49082 Tracheostomy 31.1 31600 Cardiopulmonary resuscitation 92950 Genitourinary Urethral dilatation 58.6 53600 Cystoscopy 57.32 52320 Hydrocelectomy 61.2 55040 Spermatocelectomy 63.2 54850 Circumcision 64.0 54161 Total of All Minor Surgeries Page 14 - COPT/R-99