LCME Survey Personnel Designation Form

Survey Personnel Designation Form
Schools should submit this form before LCME survey visits (full, provisional, preliminary, or limited). LCME Staff will use the information on this form to contact the appropriate survey personnel throughout the accreditation process. The Secretariat and staff are available to assist you throughout the survey preparation process. If you have questions or need advice, contact lcme@aamc.org or 202-828-0596.
School Name*
Dean Contact Information
Please list the name, degree(s), and title as the dean would like the contact information to appear in formal LCME correspondence (accreditation letters communicating LCME decisions). The email address will be used to send an electronic copy of formal LCME correspondence; please provide the email address preferred for this purpose.
Dean First Name*
Dean Middle Name or Initial
Dean Last Name*
Degree(s) *
Title*
Dean Direct Phone Number*
Provide a number, whether cell phone or direct office phone, the dean would like the LCME Secretariat to use to contact for accreditation actions (i.e., determinations after LCME meetings).
Extension
Provide the extension, if needed, to reach the dean directly.
E-mail*
Mailing Address
Street Address *
Street Address
Street Address
City*
State/Territory*
Zip Code *
Dean's Administrative Assistant Information
Please list the name, degree(s), and title as the dean's administrative assistant would like the contact information to appear in formal LCME correspondence (accreditation letters communicating LCME decisions). The email address will be used to send an electronic copy of formal LCME correspondence; please provide the email address preferred for this purpose.
Dean's Administrative Assistant First Name
Dean's Administrative Assistant Middle Name or Initial
Dean's Administrative Assistant Last Name
Degree(s)
Title
E-mail
example@example.com
Mailing Address
Street Address *
Street Address
Street Address
City*
State/Territory*
Zip Code *
Phone Number*
Provide a number the dean would like the LCME Secretariat to use to contact for accreditation actions.
University President or Chancellor Contact Information
Please list the name, degree(s), and title as the president/chancellor would like the contact information to appear in formal LCME correspondence (accreditation letters communicating LCME decisions after survey visits).
University President or Chancellor First Name*
University President or Chancellor Middle Name or Initial
University President or Chancellor Last Name*
Degree(s) *
Title*
School Name*
E-mail*
Mailing Address
Street Address *
Street Address
Street Address
City*
State/Territory*
Zip Code *
Phone Number*
Faculty Accreditation Lead Contact Information
The Faculty Accreditation Lead (FAL) is an experienced faculty member or senior administrator with extensive knowledge of the school and its programs. This individual manages the self-study process, coordinates the collection of survey data and materials, synthesizes and edits narrative answers and develops the survey visit schedule with the team secretary. The FAL will be the primary point of contact for the Secretariat and the survey team secretary.

The email address of the FAL will be added to the Connecting with the Secretariat distribution list. These webinars are meant the assist schools with upcoming survey preparation. Participants may unsubscribe at any time by emailing lcme@aamc.org.
FAL First Name*
FAL Middle Name or Initial
FAL Last Name*
Degree(s) *
Title*
Phone Number*
E-mail*
Survey Visit Coordinator Contact Information
The Survey Visit Coordinator (SVC) is an experienced senior staff member who will manage the logistics of the survey visit and other administrative functions such as formatting and submitting the survey package. The SVC will typically make hotel reservations for the team, coordinate ground transportation for the visit, and schedule the necessary faculty and staff identified for the sessions during the survey visit.

The email address of the FAL will be added to the Connecting with the Secretariat distribution list. These webinars are meant the assist schools with upcoming survey preparation. Participants may unsubscribe at any time by emailing lcme@aamc.org.
SVC First Name*
SVC Middle Name or Initial
SVC Last Name*
Degree(s)
Title*
Phone Number*
E-mail*
E-mail of person who submitted form*
This form submitted by *

First NameLast Name
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Survey Personnel Designation Form

Dean Contact Information

Dean's Administrative Assistant Information

University President or Chancellor Contact Information

Faculty Accreditation Lead Contact Information

Survey Visit Coordinator Contact Information