Application for Fellowship & Distinguished Fellowship
Nominee/Applicant Contact Information
Name
*
First Name
Last Name
Degree
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Which type of fellowship are you applying for?
Fellow
Distinguished Fellow
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Fellow Certification Information
I certify that I have met the following requirements for Fellowship in the ACOEP because of my current certification by the:
*
AOBEM
ABEM
I am not certified by AOBEM or ABEM
Fill in your AOBEM or ABEM certificate number
Fill in recertification date (if applicable)
Membership and Meeting Attendance Information
Have you had continuous membership in the ACOEP for at least five years prior to the next ACOEP Spring Membership Meeting? (Resident membership included)
*
Yes
No
Write the year you became a member of ACOEP
Have you attended at least two ACOEP General Membership Meetings in the five-year period prior to this application? You must have signed in on the meeting app or on a form or confirmed attendance with the Membership Director.
*
Yes
No
Write which membership meetings you have attended (Example: Spring 2015, Fall 2017)
Have you attended at least two ACOEP-sponsored national CME meetings in the five-year period prior to application for Fellowship? These may include: ACOEP's Intense Review; COLA Essentials (2022-2008 only); Oral Board Review, New Frontiers in Toxicology; Spring Seminar; or the Scientific Assembly - you must be a registered participant to utilize this for qualification. (Include CME certificated in the next question)
*
Yes
No
Write which meetings you attended and the course titles here:
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Fellow Qualifications
In order to qualify for fellowship, you must have high professional standing, as evidenced by two of the following. Please check all that apply to you and give requested details in the following section.
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Publication of scientific articles or reference materials in the field of Emergency Medicine in nationally peer-reviewed periodicals (must be post-residency). List your most recent publication citation in the space below.
Past or present membership on an ACOEP Committee. List the committee name and dates of service in the space below.
Past or present member of the ACOEP Board of Directors. List the dates of service in the space below.
Active involvement in student/resident education in Emergency medicine at one of the following levels: a) Current Faculty appointment OR b) Emergency Medicine Program Director or Core Faculty member. If current faculty, write your academic rank and institution in the space below. If EM Program Director of Core Faculty, write the Hospital name and date in the space below.
Current and active involvement in the leadership and education in EMS, including but not limited to: a.) EMT, First Responder, EMD, and/or paramedic training AND/OR b.) Working as a Medical Director of a Community EMS System AND/OR c.) Participation in local disaster planning and implementation. Current is defined as within the last five years.
Advanced degree or fellowship training. Write the fellowship or degree attained and include the institution and graduation date in the space below.
Past or present activity as an Examiner for or involvement in test development and/or administration of the American Osteopathic Board of Emergency Medicine (AOBEM) or the American Board of Emergency Medicine (ABEM). Describe and provide the dates of the activity in the space below.
Past or present membership on the Board of Trustees of the Foundation for Osteopathic Emergency Medicine (FOEM). List your dates of service in the space below.
Verifiable significant contribution to the specialty of emergency medicine that occurred within the past five years. Describe this contribution in the space below.
Please use this box to describe and clarify your selections above, being sure to provide any of the requested information for your selection.
*
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Distinguished Fellow Certification Information
I certify that I have met the following requirements for Fellowship in the ACOEP because of my current certification by the:
*
AOBEM
ABEM
I am not certified by AOBEM or ABEM
Fill in your AOBEM or ABEM certificate number
Fill in recertification date (if applicable)
Membership and Meeting Attendance Information
Have you had continuous membership in the ACOEP for at least ten years prior to the next ACOEP Spring Membership Meeting? (Resident membership included)
*
Yes
No
Write the year you became a member of ACOEP
Have you attended at least five ACOEP General Membership Meetings in the ten-year period prior to this application? You must have signed in on the meeting app or on a form or confirmed attendance with the Membership Director.
*
Yes
No
Write which membership meetings you have attended (Example: Spring 2015, Fall 2017)
Have you attended at least five ACOEP-sponsored national CME meetings in the ten-year period prior to application for Fellowship? These may include: ACOEP's Intense Review; COLA Essentials (2022-2008 only); Oral Board Review, New Frontiers in Toxicology; Spring Seminar; or the Scientific Assembly - you must be a registered participant to utilize this for qualification. (Include CME certificated in the next question)
*
Yes
No
Write which meetings you attended and the course titles here:
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Distinguished Fellow Qualifications
In order to qualify for fellowship, you must have very high professional standing, as evidenced by four of the following. Please check all that apply to you and give requested details in the following section.
*
Publication of scientific articles or reference materials in the field of Emergency Medicine in nationally peer-reviewed periodicals (must be post-residency). List your most recent publication citation in the space below.
Past or present membership on an ACOEP Committee. List the committee name and dates of service in the space below.
Past or present member of the ACOEP Board of Directors. List the dates of service in the space below.
Active involvement in student/resident education in Emergency medicine at one of the following levels: a) Current Faculty appointment OR b) Emergency Medicine Program Director or Core Faculty member. If current faculty, write your academic rank and institution in the space below. If EM Program Director of Core Faculty, write the Hospital name and date in the space below.
Current and active involvement in the leadership and education in EMS, including but not limited to: a.) EMT, First Responder, EMD, and/or paramedic training AND/OR b.) Working as a Medical Director of a Community EMS System AND/OR c.) Participation in local disaster planning and implementation. Current is defined as within the last five years.
Advanced degree or fellowship training. Write the fellowship or degree attained and include the institution and graduation date in the space below.
Past or present activity as an Examiner for or involvement in test development and/or administration of the American Osteopathic Board of Emergency Medicine (AOBEM) or the American Board of Emergency Medicine (ABEM). Describe and provide the dates of the activity in the space below.
Past or present membership on the Board of Trustees of the Foundation for Osteopathic Emergency Medicine (FOEM). List your dates of service in the space below.
Verifiable significant contribution to the specialty of emergency medicine that occurred within the past five years. Describe this contribution in the space below.
Please use this box to describe and clarify your selections above, being sure to provide any of the requested information for your selection.
*
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Nominating Fellow Information
Please provide contact information and a letter of recommendation from your nominating fellow.
Full Name of nominating fellow
*
First Name
Last Name
Degree
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Attach the recommendation letter from the current ACOEP Fellow who nominated you.
*
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CV, Headshot, and Confirmation Document Uploads
Attach your CV
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2. Please Attach a clear headshot (passport sized preferable) that you would like printed in a program or press release.
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By signing below I certify that the above facts are true and correct to the best of my knowledge and belief.
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Date
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