Association for Surgical Education
Academy of Clerkship Directors
Application Form
Last Name: _______________________________________________________________
First Name: _______________________________________________________________
Middle: ___________________________
Degree: ___________________
Title: _____________________________________________________________________
Office Address 1: _____________________________________________________________
Office Address 2: _____________________________________________________________
City: __________________________________________
State: ________________________
Zip: _________________________
Phone: Ext. _____________________________________________________
Fax: __________________________________________________
Cell: __________________________________________________
Email: ____________________________________________________________________
Administrative Assistant: ______________________________________________________
Phone: Ext. ____________________________
Email: ___________________________________________________________
Clerkship Coordinator: ________________________________________________
Phone: Ext. ____________________________
Email : ___________________________________________________________
Medical School : _____________________________________________________________
Campus Role (if applicable)
_Clerkship Director
_Associate/Assistant Clerkship Director
_Other (with textbox)
Verification Process Details:
To obtain certification an applicant must have at least THREE years of experience as a Clerkship or Associate/Assistant Clerkship Director and additional activities to accumulate 12 credits from the following list
Application Fee is $200.00.
Documentation must be submitted electronically. Application fee must be paid at time of submission. Visa, MasterCard and American Express are accepted. You can also mail a check made payable to the ASE to: Association for Surgical Education, 3085 Stevenson Dr., Suite 200, Springfield, IL 62703. The application fee is not refundable.
If there are any questions please contact Brenda Brown at the ASE office at 217-529-6503
Once the above documentation has been received, reviewed by the Oversight Committee (OC) and approved, the applicant will be notified of their application status. Final acceptance and level of Certification are at the discretion of the OC.
Please fill in the blanks below with number of years/presentations/publications, if applicable. (OC will calculate the credits)
years as Clerkship Director (2 credits/year with maximum of 8 credits)
years as Associate/Assistant Clerkship Director (1/2-2 credits/year, with max. of 8 credits at discretion of the OC)
Check all that apply below and supply additional information requested:
Chair/Vice Chair ASE Committee (List Committee/year(s)) _____________________________________
Attendance at ACS Surgeons as Educators course (1 credit/yr. attended-list yr.(s)) ________________________
Mentored educational project pertaining to clerkship issues (title/year) __________________________________
Attendance at CD Committee “Troubleshooting” Workshop (1 credit per year attended) Attendance at ASE “New CD” Workshop (year) _________________
Presentation at CD Committee “Troubleshooting” Workshop (1 credit per presentation) Completion of SERF project related to medical student education
Podium presentation at national meeting on education (1 credit)
Published educational research articles in peer-reviewed journal (1 credit)
Teaching scholarship awards/honors, other educational/professional activities (points to be determined by OC)
(Please list awards/activities) _____________________________________________________________________
Reminder: The following items must be enclosed: (Partial applications will be returned without review.)
? Completed Certification application
? Two letters of recommendation from your educational institution:
? for Clerkship Directors: Dean of Education (or equivalent), Department Chair
? for Associate/Assistant Directors: Clerkship Director (outlining specific role), Department Chair
? Curriculum vitae
? Educators Portfolio (if needed for documentation)
? Photo jpeg
? Additional documentation to support educational activities