Scientific Committee
Application form for a Forum Chair position
Full name
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Title
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Prof. Dr
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City
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ESAIC Membership number
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Email
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example@example.com
Secondary email (if any)
example@example.com
I'm applying for the chair position in:
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Forum 1 - General Anaesthesiology & Perioperative Medicine
Forum 2 - Patients
Forum 4 - Therapies
Forum 5 - Devices & Technology
Applicants may apply for only one position within the Scientific Committee. Multiple or simultaneous applications will not be considered.
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1. Scientific Profile and Expertise
1.1 Please describe your core scientific expertise and how it directly relates to the scope of the forum you are applying for:
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0/2500
1.2 List up to five key publications from the past five years that are most relevant to the forum:
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1. 2. 3. 4. 5.
0/2000
Please indicate your Hirsch Index (h-index) obtained via SCOPUS only.
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1.3 Describe your experience in organising, chairing or contributing to national or international scientific meetings, courses or educational programmes:
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Applicants must have an established international network in the field they are applying for. Please provide details.
0/2500
Scientific Forum Chairs must be apt to serve as speakers in relevant scientific and educational programmes organised by the ESAIC, including Euroanaesthesia.
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I hereby confirm my full proficiency in spoken English and my capability to deliver lectures on an international stage.
Share a link to a short video of a presentation you’ve delivered in English.
This can be from any context (academic, professional, or other).
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2. Added-Value and Vision for the Forum
2.1 What new perspectives, skills or approaches would you bring to this forum that are not currently sufficiently represented? Please be specific and realistic. Examples may include:
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• Scientific or methodological innovation: • Interdisciplinary collaboration: • Diversity of viewpoints or geographical reach: • Educational or strategic development:
0/2500
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3. Contribution to ESAIC and Engagement
3.1 What do you consider your most valuable contribution to ESAIC?
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If you have not previously held a formal ESAIC role, please describe other contributions that demonstrate your engagement with another society and its mission.
0/2500
3.2 Availability and engagement: Please confirm and briefly explain your ability to commit sufficient time to this role and how you ensure follow-through alongside clinical duties?
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0/2500
3.3 List all the roles you CURRENTLY hold in other ESAIC Committees and/or other scientific societies:
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4. Collaboration and Values
Working within ESAIC values:
ESAIC Code of Conduct
4.1 Describe how you ensure that your contributions align with the ESAIC Code of Conduct, particularly with regard to collaboration, managing conflicts of interest and inclusiveness:
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0/2000
4.2 Please declare any conflict of interest, i.e. relationship or arrangement with a commercial company, direct or indirect, that could be reasonably considered to affect the work in the Scientific Committee
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I have no potential conflict of interest to report.
I, or my spouse/partner, have the following potential conflict of interest(s) to report:
Receipt of grant/research support
Receipt of honoraria or consultation fee
Participation in a company sponsored speaker’s bureau
Stock shareholder
Other support (please specify)
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Finalise your application
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I have read and agree to comply with the ESAIC Code of Conduct.
I confirm that I will declare and manage any conflicts of interest according to ESAIC policies.
I understand that insufficient engagement or breach of ESAIC principles may result in non-renewal or termination of the mandate.
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