ABVO Supervising Diplomates (SD) and External Participants (EP)

ABVO Supervising Diplomates (SD) and External Participants (EP)
SDs, EPs are required to complete this ABVO notification form if they are:

1) Becoming an SD or EP for the first time
2) After a time lapse, changing or adding additional residents that they oversee
3) Exiting from a current residency program and will be replaced by another SD or EP (Note: These Diplomates must also submit a ‘Credentials Supervising Diplomate form’ for their resident(s), no more than 30 days post notice. This form is available in your ABVO.us Diplomate portal.)
(Contact the Credentials Chair or ABVO office with any questions.)

Submission and confirmation received via the below form are the only official means of communication to the Residency Committee in this matter. Emails to the office and to the Residency about such changes will no longer be accepted.
SD or EP INFORMATION
Name*

First NameLast Name
University/Clinic Name*
Email*
Direct Phone
Select Type of Change*

I am becoming a Supervising Diplomate for an approved ABVO residency program.I am becoming an External Participant for an approved ABVO residency program.I am changing and/or adding resident(s) whom I supervise.I will no longer be an SD or EP for a resident for which the Residency Committee has me listed.
IMPORTANT! Before completing this form to remove your status as an SD or EP, you must submit the “Certifying Examination Supervising Diplomate Form" for credentials. This is available when signed in to your ABVO portal, located directly under the ‘Supervising Diplomate Forms’ tab. If this is not submitted through the portal first, you will lose all access to all SD forms on the portal and not be able to complete these for residents in the future.
COMPLETE 1-3 APPROPRIATE ITEM(S) BELOW:
Date I want the above change to occur:

MonthDayYear
Date I will add new resident(s) to my SD or EP role:

MonthDayYear
Date I will terminate as SD or EP role for this resident:

MonthDayYear
Name of resident(s) and their program completion year:*
Name of SD replacing me for the above named resident when I leave (if applies):
Please provide any additional comments to the Residency Committee:
Should be Empty: