• Neonatal Surveyor Interest Form

  • Image field 3

  • Contact Information

  • Format: (000) 000-0000.
  • 2. What is your gender identity?*
  • 3. Please select the pronouns you use:*
  • 4. What is your race or ethnicity?*
  • 5. What is the surveyor role appointment you are applying for?*
  • Image field 99

  • Neonatologist Applicant

    Neonatal surveyor appointments are made based on knowledge, expertise, and experience. The NICU Verification Program upholds the AAP Statement on Diversity and Inclusion and encourages individuals of diverse backgrounds and perspectives to apply for surveyor appointments. Neonatologist applicants must be members of the American Academy of Pediatrics (AAP) and the Section on Neonatal Perinatal Medicine (SONPM), and membership dues must be current.

  • 7. Is your SONPM membership current?
  • 8. Are you currently engaged in the clinical coordination and management of neonatal care?
  • 11. What is the highest level of neonatal care in which you are clinically practicing?*
  • 15. Are you currently meeting your MOC Requirements in Neonatal-Perinatal Medicine?*
  • 16. Please identify the following activities that fall under the scope of your professional responsibility. Please check all that apply:*
  • 17. Are you currently active or have you previously been active in any state chapter(s) or national AAP committees/sections/councils?*
  • 20. Are you currently or have you previously been involved in a regional, state, or national neonatal or perinatal quality collaborative?*
  • 0/510
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Image field 100

  • Neonatal Nurse Applicant

    Neonatal surveyor appointments are made based on knowledge, expertise, and experience. The NICU Verification Program upholds the AAP Statement on Diversity and Inclusion and encourages individuals of diverse backgrounds and perspectives to apply for surveyor appointments. Neonatal nurse applicants must be members of the National Association of Neonatal Nurses (NANN) and membership dues must be current. 

  • 7. Is your NANN membership current?*
  • 8. Are you currently engaged in the clinical coordination and management of neonatal care?*
  • 11. What is the highest level of neonatal care in which you are clinically practicing?*
  • 14. Please indicate which of the following professional nursing certifications you currently maintain:*
  • 15. Please identify the following activities that fall under the scope of your professional responsibility. Please check all that apply:*
  • 16. Are you a current member or have you previously been a member of a professional nursing organization in addition to NANN?*
  • 17. Do you currently or have you previously had an active leadership role in any professional nursing organization(s)*
  • 20. Are you currently or have you previously been involved in a regional, state, or national neonatal or perinatal quality collaborative?*
  • 0/510
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Image field 101

  • Pediatric Surgeon Applicant

    Neonatal surveyor appointments are made based on knowledge, expertise, and experience. The NICU Verification Program upholds the AAP Statement on Diversity and Inclusion and encourages individuals of diverse backgrounds and perspectives to apply for surveyor appointments. Pediatric surgeon applicants must be members of the American College of Surgeons (ACS). 

  • 7. Are you currently engaged in the clinical coordination and management of neonatal care?*
  • 13. Are you currently meeting ABS Continuous Certification Requirements?*
  • 14. Please identify the following activities that fall under the scope of your professional responsibility. Please check all that apply:*
  • 15. Are you currently active or have you previously been active in any state chapter(s) or national AAP committees/sections/councils?*
  • 16. Are you currently involved, or have you previously had any involvement with the ACS – Children’s Surgical Verification (CSV) Quality Improvement Program?*
  • 19. Are you currently or have you previously been involved in a regional, state, or national neonatal or perinatal quality collaborative?*
  • 0/510
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: