ACS SRRA Psychometric Pilot Enrollment Form

2026 ACS SRRA Enrollment Form
Did your program participate in the ACS SRRA last year?
How did you learn about the ACS SRRA?

Other
Program Enrollment

Only entering PGY-4 residents are eligible.
Program Name
as you would like your program's name to appear on the score reports
Enrollment Number
Only PGY-4 residents are eligible.
Total Cost (USD) = $160 x (# of residents)
The cost per resident is $160.
Administration Date (no administrations on 5/25 as ACS is closed)

MonthDayYear
If you don't know date or time, please leave blank. No administrations on 5/25 as ACS is closed.
Administration Start Time

Clock time (Hour : Minutes)

AM/PM Option
Time Zone
Second Administration Date, if needed

MonthDayYear
No administrations on 5/25 as ACS is closed.
Second Administration Start Time, if needed

Clock time (Hour : Minutes)

AM/PM Option
Contact Details
ACGME Number
Street Address
Street Address, Line Two
Room Number, Suite Number, PO Box, Department Name, Etc.
City
State/Province
Example: IL, NY, ON, etc.
ZIP / Postal Code
Program Director Information
Is your Program Director new this year?
Program Director First Name
Program Director Last Name
Program Director Email
example@example.com
Program Director Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Send the invoice to Program Director?
Program Administrator Information
Is your Program Administrator new this year?
Program Administrator First Name
Program Administrator Last Name
Program Administrator Email
example@example.com
Program Administrator Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Send the invoice to Program Administrator?
Additional email to receive communication (another contact, proctor, etc.):
example@example.com
You might also find value in the ACS ERRA (Entering Resident Readiness Assessment), a formative assessment on the clinical decision-making of your entering PGY-1 residents.
Do you also plan to enroll your entering PGY-1 residents in ACS ERRA?
If interested, would you like to schedule a brief ERRA demonstration of its benefits with ACS staff?
Please use this space to share any additional information regarding your ACS SRRA enrollment or administration:
Should be Empty:

2026 ACS SRRA Enrollment Form

Program Enrollment

Contact Details

Program Director Information

Program Administrator Information