ࡱ>  g bjbj 4r\r\& 8,<6(((()u,t-$pZ%.))..%((ʆ333.F((3.33S|(О&.~H03ʋ/ʋʋ..3.....%%3.......ʋ......... > H:  Application for Hospice Medicine Council Leader Name  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Credentials  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Address  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       City  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Office Phone  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Email  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Fax  FORMTEXT       FORMTEXT       FORMTEXT       Eligibility Requirements to Apply AAHPM physician members in good standing for at least 5 consecutive years. Applicants who have not completed 5 years of physician membership will NOT have their applications reviewed. Current Hospice and Palliative Medicine sub-specialty board certification by one of the 10 cosponsoring members of the American Board of Medical Specialties (ABMS), the American Osteopathic Association Bureau of Osteopathic Specialists (ABOA), the American Board of Hospice and Palliative Medicine (ABHPM) or the Hospice Medical Director Certification Board (HMDCB). At least 5 years of post-residency professional activity predominantly in the field of hospice and palliative medicine. At least two of these years will have been in the hospice practice setting. Significant commitment to AAHPM as evidenced by committee and/or project participation and/or leadership. Two recommendation forms are required for consideration. One from any HPM clinician and one from a physician (both may be completed by physicians, but it is not required). At least one form must be completed by a current AAHPM member. Recommendations must be completed by professionals familiar with the applicants role and practice in the field of hospice. Please send this link to those persons you ask to recommend you. ( HYPERLINK "https://www.surveygizmo.com/s3/4829637/2019-Council-Leadership-Recommendation-Form" https://www.surveygizmo.com/s3/4829637/2019-Council-Leadership-Recommendation-Form) An attached Curriculum Vitae.(no longer than 8 pages) Applications and recommendations are due no later than February 22, 2019 at noon CT. Hospice Medicine Council Leader Application Indicate primary board certification and date and any other certifications and dates:  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       List information pertaining to serving a Hospice Medical Director and/or hospice physician. Hospital/Facility Year Role(s)  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       List information pertaining to positions held in the field of hospice and palliative medicine other than in a hospice program: Position Hospital/Facility Year Role(s)  FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       4. List any of the following offices held in AAHPM. 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h@B*CJOJQJU^JaJph#h@B*CJOJQJ^JaJph7jh@B*CJOJQJU^JaJmHnHphu,jh@B*CJOJQJU^JaJph2j< h@B*CJOJQJU^JaJph       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       5. Chair of an AAHPM committee/advisory group/task force/workgroup/SIG? Committee Year  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       6. Member, other than chair, of a committee/advisory group/task force/workgroup/SIG? Committee/Task Force/SIG Year  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       7. List any services as an editor, associate editor or contributing author for AAHPM publications, i.e. PC- FACS, AAHPM Quarterly, UNIPAC, HMD Manual, HMD Prep, Primer, etc. Publication Year Served  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       8. List participation as a presenter or faculty member at an AAHPM Education Program. Meeting/Publication Lecture Title Month/Year  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       Include a statement (200 words or less) that describes your interest in serving on the Hospice Medicine Council Leadership Team. Certification I certify that the information I gave in this application accurately represents my professional status and experience. Further, I recognize that any information on this application that is falsified may lead to the revocation of this application. 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