Information Needed to Complete the Form
Name, email, address Upload your CV ASA or SEA member ID
Recommendations:
Departmental chair or other appropriate institutional leader Name, Institution or Hospital, email Individual able to attest to the quality of their contributions to anesthesiology education Name, Institution or Hospital, email
Professional Development:
(yes or no answers) Completion of Master's Degree in EducationCompletion of PhD in EducationFaculty on SEA Workshop on TeachingCompletion of SWOTCompletion of AAMC Medical Education Research CertificateOther
Educational Research
(yes or no answers) FAER, MACY Foundation Educational Research Grant FAER Educational Research Grant SEA’d Grant Other educational research grant Editor of JPEM or another medical education journalAPSF Educational Grant Ad hoc reviewer of an educational journal Other
Publications and Enduring Materials
(number 1-20) Number of visiting professorships that included educational lecture(s) Number of non peer-reviewed publications that represent contributions to education in or about anesthesiology Number of peer-reviewed publications that represent contributions to education in or about anesthesiologyAnesthesia Toolbox Modules OpenAnesthesia Modules Patient education materials Internal local educational materials ACE or SEE ad hoc contribution Other
Educational Leadership
(yes or no answers) ASA Officer / Board of Directors ASA Annual Meeting Program Chair ASA Editorial Board Member ASA Editor-in-Chief ASA Annual Meeting Track Chair AMOC Executive Committee Member SEA Officer/Board of Directors SEA Committee Chair SEA Annual Meeting Program Chair ABA Board Member RRC Chair Residency Program Director Associate Program Director Fellowship Program Director Medical Student Clerkship Director Vice Chair for Education and/or Faculty Development Designated Institutional Officer (DIO) Other
Educational Service
(yes or no answers) Health Volunteers Overseas ASA ACE & SEE Program Question Writers Refresher Course Lectures, Workshops, Problem-Based Learning Discussions, and Panel participation (number 1-20)Member of an educational track subcommittee SEA Peer coach SEA Committee Member ABA Question Writer ABA Examiner ABA Committee Member RRC Member Education committee leadership and other education activities in subspecialty societies (e.g. SPA, SNACC, SAMBA) Service to NBME (e.g. USMLE question writer) Service to AAMC Local peer teaching Other
Education Awards
(yes or no answers) Teacher of the year Departmental Institutional National InternationalOther
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