"American Orthopaedic Society for Sports Medicine 6300 N River Road Suite"
American Orthopaedic Society for Sports Medicine 6300 N. River Road Suite 500 Rosemont, Illinois 60018 Active Membership Application Name: Date: Sponsored By: (Each applicant must be sponsored by two (2) Active members of the AOSSM.) 1) 2) Instructions Deadline: November 1st The American Orthopaedic Society for Sports Medicine (AOSSM) is a professional organization for all orthopaedic surgeons with an active interest in orthopaedic sports medicine . To be considered, applicants need to provide demographic, practice and educational information and document their involvement in sports medicine through: ●Service as team physician at any level of competition; ●Service to local, regional, national and international athletic competitions; ●Education of persons providing health care to athletes; ●Continuing medical education in sports medicine; ●Research and publication; or ●Submission and presentation of papers at sports medicine functions. The application is divided into two (2) sections that must be thoroughly completed. The first section requests basic demographic, practice and education information for processing your application. The second section asks you to list those activities where you have been actively involved in sports medicine. This part of the application is critical because Society membership is reserved for individuals who are actively providing care, education or research in orthopaedic sports medicine . Since individuals may be involved in sports medicine in a variety of ways, we have provided different options for you to list your involvement. Each activity is worth a designated number of points, and applicants are expected to be involved in at least two of the Sports Medicine Activities categories. You must have at least 15 points to qualify. Special Notes 1) Your application must be completed to be considered; you cannot simply attach a CV in lieu of answering the questions. 2) You must either complete the application in Excel and submit it electronically or type a hard copy of the application. (Excel is strongly encouraged because it allows you to more readily complete, score and modify your application, as necessary.) Handwritten applications will not be accepted and will be returned to the applicant. 3) If you have an electronic signature, you may embed the signature into the appropriate portion of the application. 4) Information submitted to document your involvement in orthopaedic sports medicine should be within the last five (5) years. 5) There is a $150 application fee to apply for Active Membership. The application fee can be paid via check or credit card. To pay the application fee by check please include the check with a hard copy of your application. If you choose to pay via credit card you may do so by contacting the Society office. SECTION I: Demographic, Practice and Education Information Name: Degree: Date of Birth: Citizenship: Age: Sex: Practice Name: Office Address: Telephone: Fax: Email: Home Address: Telephone: Fax: Email: Preferred Mailing Address: Office: Home: How long have you practiced in your current geographic area? Medical License: State: Date of Issue: License Number: 1) 2) 3) Have your hospital privileges ever been suspended, revoked or not renewed? Yes (If yes, explain in detail on separate sheet.) No Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings by any medical organization? Yes (If yes, explain in detail on separate sheet.) No Has your license to practice medicine in any jurisdiction ever been suspended or revoked? Yes (If yes, explain in detail on separate sheet.) No Current Hospital Staff Appointment(s) Include name and address of the Chief of Surgery/Chief of Orthopaedics Hospital: Chief of Surgery/Chief of Orthopaedics: SECTION I: Demographic, Practice and Education Information (continued) Educational History Complete the Educational Categories that are applicable Residency University or Hospital Type of Residency Date Fellowship Name of Institution Type of Fellowship Date Teaching Appointment(s) Full-Time Faculty Rank Institution Date of Appt. Clinical Faculty Rank Institution Date of Appt. Specialty & Medical Society Membership Name Date Board Certification: Applicants are required to be certified in general orthopaedics by the American Board of Orthopaedic Surgeons (ABOS) or the Canadian equivalent. Members are not required to be certified in Orthopaedic Sports Medicine. Board Certificate Date SECTION I: Demographic, Practice and Education Information Attestation In furtherance of my application for Membership in the American Orthopaedic Society for Sports Medicine [Society] and in consideration for the Society's treatment of the entire contents of this application as well as all inquiries or investigations made pursuant thereto as privileged and confidential material: I request and authorize: a) any hospital or medical staff where I now have, have had, or have applied for medical staff privileges, and any medical organization of which I am a member or to which I have applied for membership, and any person who may have information (including medical records, patient records, and reports of committees) which is deemed by the Society to be material to its evaluation of my fitness for membership, to provide such information to representatives of the Society upon their request, and b) the Society to make whatever inquiries and investigations it deems necessary to verify my credentials, professionals standing and moral or ethical character. I agree that: a) communications of any nature made to the Society regarding my fitness for Membership shall be made in confidence and shall not be made available to me under any circumstances, and b) I will not cause or attempt to cause any public disclosure of the contents of any application for Membership in the Society, including my own, or any proceedings of any committees evaluating such applications, whether disclosure is by operation of law or otherwise. I agree that if I am admitted as a Member of the Society, I shall abide by the By-laws and rules of the Society. I understand and agree that the contents of my admission file, except the application form and a copy of any correspondence to myself indicating final action, shall be destroyed by the Society after the date of mailing such notification to me. I release from liability the Society and its officers, directors, members, agents and employees, and the providers of any information about me, and each of them, and agree to save and hold each of them harmless from and against all claims, costs and expenses (including reasonable attorneys' fees), demands, actions and liability arising from or relating to acts performed in good faith and without malice in connection with the provision, collection, or evaluation of information or opinions, whether or not requested or solicited, concerning my application for Membership in the Society. I hereby represent and warrant that the information provided on this application is accurate and complete. Signature of the applicant Date If you wish to submit your application electronically but do not have an electronic signature you may mail or fax your signature to the Society office. SECTION II: Sports Medicine Activities List below your involvement in sports medicine through team service, community service, continuing medical education, publication, research and ongoing education. List your activities within the last 5 years, and assign the designated number of points for each activity you list. Note that you must have 15 points to qualify, but you do not need to have been active in each of the following areas. You can amass the required point total through any combination of activities. Please list each activity only once. Team Service Please list all teams and sports for the past five (5) years where team service coverage is provided. Team Service points is based on the teams for which service is provided- -Professional, Collegiate, or National teams- 3 points for each year (must include sideline service or PPEs) -High School or Recreation (club) teams- 2 points for each year (must include sideline service or PPEs) The maximum number of points for this section is 10. Note: The limit for each high school per year is 2 points. Team Sport Date Points (Team Service Maximum Total 10 Points) Subtotal 0 Community Service Please list all Community Service activities related to Sports Medicine for the past five (5) years. These activities can include presentations to local organizations or community groups and episodic coverage of athletic events. Each Community Service activity is worth 1 point. The maximum number of points for this section is 5. Local Public Presentations Organization Date Points Episodic Coverage of Athletic Events Pre-Season Physicals for Schools or Teams (Do not include teams already listed under the Team Service section) (Community Service Maximum Total 5 Points) Subtotal 0 SECTION II: Sports Medicine Activities (continued) Education Please list each activity only once-presentation or publication. The maximum number of points for this section is 10. Medical Education - Faculty Include all presentations in which you served as faculty -- CME, GME or University. Each activity in under Medical Education - Faculty is worth 1 point. Title/Presentation Organization Date Points Medical Education Subtotal 0 Publications Please include all publications in which the applicant was author or co-author. Publications points are based on the following: -Peer-reviewed and Sports Medicine publications- 2 points each -Non-peer-reviewed publications- 1 point each Title Publication Date Points Publications Subtotal 0 Education Maximum (Medical Education and Publications) Total 10 Points 0 SECTION II: Sports Medicine Activities (continued) Meeting Attendance List attendance at any AOSSM sponsored Sports Medicine related CME meetings in the past five (5) years. Applicants must have attended at least one AOSSM Annual Meeting in the last five (5) years. Meeting attendance point- -AOSSM Annual Meeting- 2 points per Meeting -Any AOSSM Sponsored Meeting- 1 point per Meeting There is no maximum amount of points for Meeting Attendance. Meeting Organization Date Points Subtotal 0 Practice Percentage Please calculate the percentage of practice in Sports Medicine. The practice percentage should represent the portion of your practice in which you provide sports medicine care to patients. Please use the following weighted point system: -20% or more- 1 point -40% or more- 2 points -60% or more- 3 points Points Practice Percentage 0 (Maximum Total 3 Points) Grand Total Points 0