AVMA-AFSCAN Twinning Program Application

AVMA-AFSCAN Twinning Program Application

Please complete all segments of the application below by April 1, 2020.

Questions regarding the AVMA-AFSCAN Twinning Program or the application process?

U.S.-based clinics should contact Dr. Beth Sabin, AVMA Director of Global Outreach: esabin@avma.org | +1-847-285-6711
African-based clinics should contact Dr. Kevin Stevens, Twinning Program Coordinator: kvet@eastcoast.co.za | +27-82-448-6449

ANIMAL HEALTH CARE TEAM MEMBER INFORAMTION

1. Please provide the requested information for the Primary Veterinarian (if two Primary Veterinarians are selected, please include information requested below for both).

Professional degree(s)

Specialty certification (if any)

Email address

Country Code Area Code Phone Number

WhatsApp number

Position at clinic (eg. owner, associate, practice manager)

Professional association memberships

Please attach a brief CV/resume (1-2 pages maximum)

Browse Files

2. If applicable, please provide names of other animal health care team members (veterinarians and non-veterinarians) participating on a regular basis in Twinning Program activities. Additional animal health care team members may be added later.

CLINIC INFORMATION

3. Clinic name

Name

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Country Code Area Code Phone Number

Web site

4. Type of practice (e.g., companion animal exclusive, mixed animal/companion animal predominately, specialty, general practice, emergency)

5. Size of practice (number of veterinarians, technicians/nurses, assistants, office staff and approximate monthly case-load)

6. Practice resources

Radiography and other imaging modalities Surgery (e.g., does your clinic offer both soft tissue and orthopedic surgery) Laboratory (in-house equipment)

TWINNING PROGRAM INFORMATION

7. Briefly outline why your clinic and animal health care team want to participate in the AVMA-AFSCAN Twinning Program; that is, what are your goals and objectives for participating?

8. Please confirm that you and other health care team members who will regularly participate in the twinning program can commit the following:

a. At least 1 hour per month for virtual clinical rounds with your twinned clinic,plus any time need to prepare case presentations.

Yes No

b. At least 1 hour per month for less formal communication with your twinned clinic on cases, clinic management, general questions, or any other program-related business.

Yes No

c. At least 1 hour per quarter for virtual grand-rounds with all other twins.

Yes No

d. Providing a brief written summary of twinning activities once per quarter to Twinning Program Coordinator; summary may be shared with program partners.

Yes No

If you responded no to any of the above questions, please explain: