PSPS Leadership Immersion Tract (LIT) Application
Deadline: October 31, 2026
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
City and State of Residence
Current Institution / Practice
If accepted, you will be placed on one committee. Please rank all six committees in order of your interest, with 1 indicating the committee you’d most like to join. Your preferences will help us place everyone.
*
Professional Background
Primary Specialty
Additional Specialty or Subspecialty (if applicable)
Current Training / Career Stage
Medical student
Resident
Fellow
Practicing physician
Other
PGY (if applicable)
If Currently in Fellowship:
Fellowship Year
Fellowship Specialty
Fellowship Institution
Expected Completion Date
If Fellowship-Trained or in Independent Practice:
Fellowship Completed (specialty and institution)
Year Fellowship Completed
Number of Years in Independent Practice
Practice Information
Practice type
Academic / University
Private Practice
Hospital-employed
Multispecialty group
Hospital-based Practice
Ambulatory Surgery Center
Other
Primary Clinical Focus (select all that apply)
Interventional Pain Management
Non-interventional Pain Management
Physical Medicine & Rehabilitation
Anesthesiology
Neurosurgery
Orthopedic Spine Surgery
Neurology
Other
Primary Practice Location / Region
States or Regions Served
Leadership Experience and Interests
Have you previously participated in any professional society, committee, or leadership program?
Yes
No
If yes, briefly describe your involvement
What are your primary professional interests? (Select up to three.)
Clinical Education
Research and Scholarly Activity
Advocacy and Healthcare Policy
Practice Management and Business Development
Quality Improvement and Patient Safety
Multidisciplinary Collaboration
Medical Technology and Innovation
Committee or Society Leadership
Other
Why are you interested in participating in the PSPS Leadership Immersion Track?
What strengths, experiences, or perspectives would you bring to the LIT cohort and PSPS?
How would you like to contribute to PSPS during and after the program?
Commitment to the Two-Year Program
Please confirm your understanding of the following expectations:
I understand that LIT is a two-year leadership development program.
I am willing to attend monthly virtual LIT meetings and participate actively in discussions and program activities.
I am willing to participate in PSPS committees, projects, or other society initiatives.
I intend to attend at least two PSPS meetings or major society events during the program, subject to scheduling and professional obligations.
I am willing to develop and work toward individualized leadership goals and contribute to a meaningful project or initiative during my participation.
I understand that active participation, professionalism, responsiveness, and sustained engagement are important components of successful program completion.
Professional Reference / Mentor
Optional
Name
First Name
Last Name
Credentials
Email
example@example.com
Is there anything else the selection committee should know about your background, interests, or goals?
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Applicant Attestation
I certify that the information provided in this application is accurate and that, if selected, I intend to participate actively in the PSPS Leadership Immersion Track and contribute to the mission of the Pacific Spine & Pain Society.
Applicant Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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