CANADIAN ACADEMY OF SPORT MEDICINE ACADÉMIE CANADIENNE DE MÉDECINE DU SPORT “Committed to Excellence L’excellence dans la pratique” Application for the Diploma Examination in Sport Medicine for the Canadian Academy of Sport Medicine General Information Applications are now being accepted individuals wishing to sit the Diploma Examination in Sport Medicine, conducted by the Canadian Academy of Sport Medicine (CASM) in the Spring of 2008. Applications are available upon request by writing to: The CASM Executive Director, Canadian Academy of Sport Medicine 5330 Canotek Road, Unit 4 Ottawa, ON, K1J 9C1 Completed application forms, together with the application fee, must reach the CASM National Office no later than the specified date. The application form is not complete without the signature of the applicant, the application fee and a passport-style photograph of the applicant. No payment The application fee is $1200.00 Cdn. Examination candidates will be selected on a "first come first served" basis. Every two year, accommodations will be made for candidates to write the exam in French. Francophone candidates will be given priority for that year, if a minimum number of Francophone candidates is reached. The exam will be offered in French at least every 4 years. Priority is also given to fellows registered in Sport Medicine fellowship programs and those who have failed the previous year (see below for specific information on priority applications). The applicants accepted for examination will be notified by the CASM Executive Director, and will be provided with information about the centre where he/she will take the examination. In the event that an applicant qualifies to sit the examination but is unable, for whatever reason, to sit the exam, the application fee of $1200 will be forfeited except for an administration fee of $500, which can be applied to one of the next two subsequent examinations. (For complete details please refer to Refund Policy). Future applications to sit the examination can be made upon payment of the appropriate application fee. The Examination The examination is predominantly conducted using OSCE situations but other forms of examination can be used as well, ie multiple choice or short answer questions. These are designed to simulate, accurately as possible, situations that are likely to arise in the context of the practice of clinical sport medicine. They are designed to evaluate and assess, not only knowledge, but also clinical skills and behaviour. Applicants who have been involved in the clinical practice of sport medicine, are familiar with the current literature, have participated in ongoing CME activities in this area, and who are aware of contemporary issues in sport medicine are ideal candidates for the examination. More information can be obtained by reading "The Diploma Examination in Sport Medicine" a publication of the Canadian Academy of Sport Medicine. A candidate can sit the exam three times; a third failure will require an independent review by the committee. Priority - Failed candidates receive priority to sit the next available exam, one time only. - Fellows receive priority to sit the exam immediately following completion of their Fellowship. - Francophones will receive priority on the list of the year the exam is held in French only, based on date of receipt of application. Eligibility Candidates for the CASM Diploma Examination in Sport Medicine must meet the following criteria (Approved by the CASM Board of Directors in May of 2006): All candidates must be members in good standing of the CASM at the time they apply to sit the examination and must fulfill the following requirements: A minimum of 2 years of independent MEDICAL practice, which must include attendance at one provincial or national sport medicine conference and documented participation of 50 hours of team/sport/event coverage OR The candidate must possess a CCFP and have completed a one-year Sport Medicine fellowship at a recognized University Medical Center. * OR The candidate must be a Fellow of the Royal College of Physicians and Surgeons and have completed a one-year Sport Medicine fellowship at a recognized University Medical Center. * (* For candidates taking a one year Sport Medicine Fellowship and who take the exam before the full completion of that year, the Diploma will be sent upon successful completion of the fellowship year.) Physicians practicing outside Canada must be licensed to practice in their country or residence and fulfill the criteria noted above. All who are interested in sitting the Exam should submit an application form with the appropriate fee by the announced deadline. This is usually 7 months before the exam date.) Please note that applications are accepted throughout the year, on a first-come, first-serve basis. The Credentials Committee reviews applications periodically throughout the year, as required. Applications will not be considered complete unless the candidate is a member (Active Category) in good standing of the Academy. Successful candidates may use Dip. Sport Med. as a nominal. The use of this designation is contingent upon ongoing membership in the Canadian Academy of Sport Medicine. Please contact the National Office to receive an application form. Interest in the CASM Diploma Exam in Sport Medicine continues to increase, as does the number of applicants. Please submit your application promptly. Candidates unsuccessful in passing the examination in previous years are encouraged to repeat the examination in a subsequent year. Such candidates need not submit an application form but must submit a letter of intent to sit the examination no later than the specified application deadline date for that year. The application fee should accompany this letter. Application for "The Diploma Examination in Sport Medicine" Application Date:_______________________________ Name in full (Surname) (Given name) Address Tel. No.__________________ (office) Tel. No.___________________ (City) (Province) (Postal Code) (home) Fax No.___________________ Email_____________________________________ Sex Citizenship Date of Birth ____________________________ Language Preference English French (To take the exam) Medical Education Medical School_________________________________ Degree(s)__________________________________ Date of Graduation___________________________ Other Medical Qualifications and/or Degrees___________________________ Internships : University Type Date____________ Type Date____________ Residencies : University Type Date____________ Type Date____________ Fellowships : Location Type Date____________ University Teaching Appointments (Please list) a) How many years in Active Practice? (location with dates): i) ______ ii) ______ iii) ______ iv) ______ b) What proportion of your practice time is given to sport medicine (Approx. % of time):__________ c) Are you engaged in the following areas of practice and to what degree? FAMILY PRACTICE SPECIALTY _________________ % Sport Medicine_____________ % Research_________________ % Teaching_________________ d) Are you now an active member of Canadian Academy of Sport Medicine? _____ Yes _____ No (If no, please enclose a completed application for membership and include the membership fee with payment of the examination fee.) Declaration In submitting this application to sit the examination for the Diploma in Sport Medicine of the Canadian Academy of Sport Medicine, I declare the following: 1) I am in possession of a license to practice medicine. 2) I have met all eligibility criteria as stated above and have submitted my documented hours of sport coverage. 3) I am a member of the Canadian Academy of Sport Medicine or will enclose an application for membership. Signature Date__________________________ Example of Acceptable Photograph Showing a full front view of the head and shoulders without head covering taken against a plain white background. Photographs should normally measure 2 x 2 3/4 inches including ½ blank signature space at the bottom, which forms part of the photographic print. Please Note This application cannot be processed unless it is accompanied by the following: 1) one signed "acceptable" photograph; please paperclip to application 2) application fee of $1200.00 Canadian. CANADIAN ACADEMY OF SPORT MEDICINE ACADÉMIE CANADIENNE DE MÉDECINE DU SPORT “Committed to Excellence L’excellence dans la pratique” REFUND POLICY 2008 CASM DIPLOMA EXAM IN SPORT MEDICINE All interested candidates are required to submit their completed application form and exam fee of $1200.00 to confirm their position to sit the 2008 CASM Diploma Exam. Date of the Exam: to be determined Location: Ontario Withdrawal or Cancellation Policy WRITTEN NOTICE OF WITHDRAWAL from the exam process MUST BE RECEIVED BY HEAD OFFICE. IF NOTICE OF WITHDRAWAL IS RECEIVED AFTER YOUR APPLICATION HAS BEEN APPROVED (ONCE THE DATE AND LOCATION HAVE BEEN CONFIRMED AND YOU HAVE AGREED TO SIT) $700 WILL BE FORFEITED. THE ADMINISTRATION FEE OF $500 CAN BE APPLIED TO ONE OF THE NEXT TWO SUBSEQUENT EXAMS. NO REFUNDS WILL BE ISSUED. Failure to provide written notice of withdrawal will result in forfeiture of the entire exam fee.