Board Qualified Status Extension Request Form

Board Qualified Status Extension Request Form
Name:*

First NameLast Name
ABFAS ID:*
Email:*
example@example.com
Phone Number*
Please enter a valid phone number.
For which status type(s) are you requesting an extension?*

Foot Surgery Status OnlyRRA Surgery Status OnlyBoth Foot and RRA Surgery Status
Please note: You may only submit extension requests in your final year of Board Qualified status.
Extension Request Reason*

Family (family support, caregiver, pregnancy, maternity/paternity leave, etc.)Professional (career changes/moves, unemployment, lack of surgical cases, etc.)Health (personal health issues, non-pregnancy/family member care)COVID (COVID-19 surgical case delay or other impact on practice/life)Exam (exam registration or eligibility issue, case documentation issue, or exam concern)Fellowship (surgical case accrual delay due to one or two-year fellowship after residency)
Extension Request Details*
Explain in detail the extenuating circumstances that require an extension of your Board Qualified status.
Upload Supporting Documentation

Provide any additional documentation that supports your extension request (e.g., hospital privileges, license documentation, etc).
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Please note: Submission of a request for an extension does not guarantee approval. ABFAS has discretion to approve or deny each request. The ABFAS Board of Directors determines whether to approve each properly submitted extension request, each of which is presented to the Board anonymously, with all personally identifiable information redacted.
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