AHRA Fellow Application

AHRA Fellow Application

The AHRA Fellow designation recognizes the significant contributions of AHRA members to our professional association.
Using the evaluation point scale and form within this form, members may submit an application for Fellow status. Applications are made to the Member Recognition Committee and require the sponsorship of a current AHRA Fellow. All applicants will be notified of the Committee's decision, and those members who qualify for Fellow status will be recognized at the Annual Meeting.
There are 4 major categories. Each of these has a minimum point requirement as well as a maximum point limit. Some items within categories also have maximum point limits.

Items from within each category are assigned a point value, indicated in parentheses. The applicant identifies the year(s) of achievement for each item and multiples that number by the point value.

Example (from Category I, Section A, Item 10):

Each at-large appointment as a member of a committee, team, task force, work group, board team, etc. (excluding annual meeting design team) for a full term of 1 month or more.

(2 points)

Appointment: Editorial Review Board | 1989-1992 | 6 Points (3 years at 2 points per year = 6 points).
All accomplishments (e.g., selected offices, committee appointments, publications, etc.) must have been completed at the time of this application in order to be eligible for consideration. For a multi-year term, each year of service must be completed before points are applied, but the multi-year term need not be completed (e.g., if you began a term in August 2009 to finish in August 2012, you can receive credit for 1 year of service after August 2010, 2 years of service after August 2011, the 3rd year of service is not eligible for credit until after August 2012).

Applicants must submit appropriate documentation to support the total point value of each category (specific types of documentation will vary; might include copies of diplomas, CE letters, title pages of articles or books, etc.). A resume or curriculum vitae is also required. Log-on to www.ahra.org (member home/view activities) to view a record of member activities. Applications submitted without supporting documentation cannot be processed.

It is the applicant's responsibility to assure that all application materials have been received by AHRA by the deadline.

Contact Details

Contact information for the Fellow applicant.
- List only completed accomplishments (each credited term of service must have been completed at the time of application).
- List each accomplishment in only one category and section.
- Application must meet category and application minimum point requirements.
- No points can be credited in each category and section above the maximum point limit.
Application MUST include:
- Completed, signed application form
- Sponsor's signature from a current AHRA Fellow
- Supporting documentation
- Resume or curriculum vitae
Full Name*

First NameMiddle NameLast Name
Application Date*

MonthDayYear
Date
Job Title*
i.e., President, Department Director, Team Lead
Department*
Full Name of Your Institution*
Please do not abbreviate your institution.
Your Address*

Street Address

Street Address Line 2

CityState / Province (Ex: IL, MI, MA, MD)

Postal / Zip Code
Country*
Please abbreviate country
Phone Number*
Please enter a valid phone number.
Phone Extension
i.e., 4480
Email*
example@example.com
Resume*

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Sponsor Information

Contact information for the AHRA Fellow providing sponsorship.
The role of the sponsor is to assist the individual applying for Fellowship status, by reviewing the application to determine readiness and if needed, identifying possible next steps if the individual has not yet met the criteria. The sponsor will present a supporting statement (recommendation) on behalf of the applicant. Sponsor must be a current AHRA Fellow.
Sponsor's Name*

First NameMiddle NameLast Name
Sponsor's Title*
i.e., President, Department Director, Team Lead
Sponsor's Department*
Full Name of Sponsor's Institution*
Please do not abbreviate the name of the institution.
Sponsor's Address

Street Address

Street Address Line 2

CityState / Province (i.e., IL, MI, MA, MD)

Postal / Zip Code
Sponsor's Phone Number*
Please enter a valid phone number.
Sponsor's Phone Extension
Sponsor's Email Address*
example@example.com

Category I: AHRA Contributions
AHRA President | Start Date | (10 Points)

MonthDayYear
Start Date
AHRA President | End Date | (10 Points)

MonthDayYear
End Date
AHRA President (10 Points)
Start Date through End Date
AHRA President-Elect (6 Points)
Start Date through End Date
AHRA Past President (6 Points)
Start Date through End Date
AHRA Board of Directors (6 Points)
Start Date through End Date
Annual Meeting Design Team Chair (6 Points)
Start Date through End Date
Annual Meeting Design Team Member (4 Points)
Start Date through End Date
Radiology Administration Certification Commission (RACC) Chair (6 Points)
Start Date through End Date
Radiology Administration Certification Commission (RACC) Commissioner (4 Points)
Start Date through End Date
AHRA Education Foundation Chair (4 Points)
Start Date through End Date
AHRA Education Foundation Director (3 Points)
Start Date through End Date
Spring Conference Design Team Chair (4 Points)
Start Date through End Date
Spring Conference Design Team Member (3 Points)
Start Date through End Date
Fall Conference Design Team Chair (4 Points)
Start Date through End Date
Fall Conference Design Team Member (3 Points)
Start Date through End Date
Each appointment of chairperson, leader, or editor of a committee, team, task force, work group, board team, etc. (excluding conference design teams) for a full term of 1 month or more, within the last 10 years. (3 points)
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Each at-large appointment of member of a committee, team, task force, work group, board team, etc. (excluding conference design teams) for a full term of 1 month or more, within the last 10 years. (2 points)
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Each appointment of chairperson, leader, or editor of a committee, team, task force, work group, board team, etc. (excluding conference design teams) for a full term of 1 month or less, within the last 10 years. (2 points)
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Each at-large appointment of member of a committee, team, task force, work group, board team, etc. (excluding conference design teams) for a full term of 1 month or less, within the last 10 years. (1 point)
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
On-site volunteer service at the Annual Meeting (1 point/3 point max)
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Appointment Appointment | Start:   Start Date | End:   End Date
Supporting Documentation for Positions Held

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AHRA Member Since:*
i.e., 1997
First 5 Years of Membership (1 point total)
i.e., 2012-2017
Each Year of Membership After the First 5 Years (1 point per year)
i.e., 5
Summary Category I: AHRA Contributions (point totals)
AHRA Long-term ContributionsLong-term Points*
AHRA Short-term Contributions Short-term Points*
AHRA Membership (maximum 10 points) Membership Points*

Total Category I Points:   Category I Total*

Category II: Education
Certified Radiology Administrator (CRA) Certification (10 points)
Start:Start Date | End:End Date
Certification by ARRT, RDMS, NMTCB or other allied health national certification requiring a minimum of 24 months of educational programs. (3 points)
Certification: Certification 1 | Start:   Start Date | End:   End Date
Certification: Certification 2 | Start:   Start Date | End:   End Date
Certification: Certification 3 | Start:   Start Date | End:   End Date
Highest advanced degree attained:Degree Name
Graduation Date:Grad. Date

Associates degree (5 points) or Baccalaureate degree (7 points) or Master's degree (10 points) or Doctorate (15 points)
Maximum 25 points

Credit given for AHRA sponsored or ARRT category A credit-approved programs only. Credits must be earned within the last five years prior to submitting application.
CEU Participation (1 point for every 5 CEUs)
i.e., 3 points for 15 CEUs
Supporting Documentation for Education

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Summary Category II: Education (point totals)
National Certification (maximum 10 points) Nat'l Total Points
Advanced Degrees Adv. Total Points
CEU Participation (maximum 25 points) CEU Total Points
Category II Summary: Total Points*
Minimum 25 points required; maximum 40 points allowed
Category II Summary: Total Points*
Category II: minimum 25 points required; maximum 40 points allowed.

Category III: Professional Experience

Submit all relevant documentation with application. Credit given for full-time work in imaging or healthcare related areas only.
Non-Management Role

(1 point per year)
From Exp. 1 Date to Exp. 1 Date
Total: Exp. 1 Points
Leadership Role with Direct Reports

Supervisor and above within Radiology (4 pts per year); Supervisor and above outside of Radiology (2 pts per year)
From Exp. 2 Date to Exp. 2 Date
Total: Exp. 2 Points
(Full time imaging or healthcare work not included in the above section only)
Supporting Documentation for Professional Experience

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Summary Category III: Professional Experience (point totals)
Non-Management: Total Points*
Leadership: Total Points*

Category IV: Professional Contributions
Maximum 40 points

*For articles with a co-author, divide points based on your actual contribution (e.g., for a Radiology Management article where the work was split between yourself and one other author, you would earn 5 points (50% of 10 points).
Feature article(s) published in Radiology Management (10 points each article; maximum 20 points)
Title:   RM Article 1   | Date Published:   Date
Contribution percentage*:   Number

Title:   RM Article 2   | Date Published:   Date
Contribution percentage*:   Number
Article(s) published in other peer reviewed professional journals (e.g., those journals found in Index Medicus/Medline) (3 points each article; maximum 12 points)
Title:   Article 1   | Date Published:   Date
Contribution percentage*:   Number

Title:   Article 2   | Date Published:   Date
Contribution percentage*:   Number

Title:   Article 3   | Date Published:   Date
Contribution percentage*:   Number

Title:   Article 4   | Date Published:   Date
Contribution percentage*:   Number
Column in Radiology Management (5 points each column, maximum 10 points)
Title:   Column 1   | Date Published:   Date
Contribution percentage*:   Number

Title:   Column 2   | Date Published:   Date
Contribution percentage*:   Number
Article in Link (2 points each column, maximum 10 points)
Title:   Link Article 1   | Date Published:   Date
Contribution percentage*:   Number

Title:   Link Article 2   | Date Published:   Date
Contribution percentage*:   Number

Title:   Link Article 3   | Date Published:   Date
Contribution percentage*:   Number

Title:   Link Article 4   | Date Published:   Date
Contribution percentage*:   Number

Title:   Link Article 5   | Date Published:   Date
Contribution percentage*:   Number
Supporting Documentation for Article Authorship

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Maximum 40 points

Presentations given independently (10 points)
Presentations given with a co-presenter (5 points)
Speaker at AHRA Annual Meeting, seminar, conference, webinar, or other AHRA educational event (10 points each hour, 5 each hour for subsequent presentations at the same lecture).

Lecture Title:   Lecture 1 Title   | Co-Presenters*:   Number
Event:   Event Name 1   | Event Date:   Date
Lecture Length:   (minutes)

Lecture Title:   Lecture 2 Title   | Co-Presenters*:   Number
Event:   Event Name 1   | Event Date:   Date
Lecture Length:   (minutes)

Lecture Title:   Lecture 1 Title   | Co-Presenters*:   Number
Event:   Event Name 1   | Event Date:   Date
Lecture Length:   (minutes)

Lecture Title:   Lecture 2 Title   | Co-Presenters*:   Number
Event:   Event Name 1   | Event Date:   Date
Lecture Length:   (minutes)
Supporting Documentation for Presentations

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Evidence-based Practice Project Submission

Study Title   Poster 1 Title   | Co-Presenters*:   Number
Event:   Event Title   | Event Date:   Date

Study Title   Poster 2 Title   | Co-Presenters*:   Number
Event:   Event Title   | Event Date:   Date
Supporting Documentation for Evidence-based Practice Project Submission(s)

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Round Table Leader AHRA Annual Meeting, seminar, conference, webinar, or other AHRA educational event. (2 points each)

Topic   Leader Topic 1   | Co-Presenters*:   Number
Event:   Event Title   | Event Date:   Date

Topic   Leader Topic 2   | Co-Presenters*:   Number
Event:   Event Title   | Event Date:   Date
Supporting Documentation for Round Table Leadership

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Sole Author of a leadership and/or medical imaging book
(40 points each book)

Book Title:   Book 1 Title
Publication Date:   Date

Book Title:   Book 2 Title
Publication Date:   Date
Author of 1 or more chapters (i.e., Professional Development Series Textbooks)
(15 points per chapter)

Chapter Title:   Chapter 1 Title
Book Title:   Type a label
Contribution (%)*:      | Publication Date:   Date

Chapter Title:   Chapter 2 Title
Book Title:   Type a label
Contribution (%)*:      | Publication Date:   Date

*For chapters with a co-author, divide points based on your actual contribution (e.g., for a textbook chapter where the work was split evenly between yourself and one author, you would earn 7.5 points (50% of 15 points).
Supporting Documentation for Book Authorship

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For example: Gold Award, Radiology Management Editorial Award, Award for Excellence, etc. (scholarships do not qualify)
(15 points each)

Award:   Award 1   | Date:   Date
Award:   Award 2   | Date:   Date
Award:   Award 3   | Date:   Date
Award:   Award 4   | Date:   Date
Supporting Documentation for Awards Received

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Summary Category IV: Professional Contributions
Article Publications (maximum 40 points):   Article Total Points*
Presenter (maximum 40 points):   Presenter Total Points*
Book Author:   Author Total Points*
Other Outstanding AHRA Achievements and AHRA Awards:   Awards Total Points*

Total Points for Category IV:   Category IV Total*

Application Point Totals
Category I: AHRA Contributions (min: 15; max: 40)
Category II: Education (min: 25; max: 40)
Category III: Professional Experience (min: 20; max: 25)
Category IV: Professional Contributions (min: 20; max: 50)
Total Points for Application (min: 120)
Other Supporting Documentation

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My signature certifies that the information in this application is true and accurate to the best of my knowledge.*

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AHRA Fellow Application

Contact Details

Sponsor Information

Category I: AHRA Contributions

Category II: Education

Category III: Professional Experience

Non-Management Role

Leadership Role with Direct Reports

Category IV: Professional Contributions

Application Point Totals