Academic Program Administrator Certification in Surgery Application

APACS: Academic Program Administrator Certification in Surgery

Verification Process Details:

Applicant must be an ASE Member.

The applicant must have a minimum of one presentation during an ASE Annual Coordinator Track Program.

A total of 12 or more credits are required. Please refer to the Academic Program Administrator Certification in Surgery Page.

Proper documentation must be submitted: CV/Resume/Photo, letter of recommendation from Clerkship Director, completion of a reflective essay to demonstrate professional growth as a result of the certification, PowerPoint presentations, and proof of credits.

Documentation must be submitted electronically

Once the above documentation has been received, reviewed by the Committee on Coordinators of Surgical Education and approved, the applicant will be notified of their application status. Final acceptance and level of Certification are at the discretion of the committee.

If there are any questions please contact the ASE office at [email protected]

Contact Infomation

Name(Required)

First Last Degree(s)

Email(Required)

Institution(Required)

I confirm that I am an ASE member in good standing.(Required)

Yes, I am an ASE member in good standing.

If you are NOT an ASE member, please apply for membership prior to completing this application. Apply here today!

Credits Earned

Total Years Served as a Clerkship Coordinator(Required)

2 credits earned per year as Clerkship Coordinator, 6 credits maximum.

Total Presentation(s) given during the Coordinator Program Track at the ASE Annual Meeting(Required)

2 credits earned per year as Clerkship Coordinator, 6 credits maximum.

I have served as a Chair or Vice Chair of the ASE Coordinator Committee(Required)

1 credit earned for serving as the Chair, Vice-Chair

Yes

I hold a leadership role on a committee within my Institution(Required)

1 credit

Yes

Total years you attended the Coordinator Track at the ASE Annual Meeting(Required)

1 credit per year attended, maximum of 3 credits.

Departmental, institutional, or non-ASE national presentation(s) given(Required)

1 credit per presentation, maximum of 3 credits. Please list year and title of the presentation. You may add a new text box for each year/presentation by clicking on the + button on the right.

Professional Development: attend qualifying workshops or seminars(Required)

1 credit per activity, maximum of 3 credits. Click the + button to add activities.

Published educational research articles/and or abstracts.(Required)

1 credit per educational research article or abstract. Click the + button to add a new text box

I have actively participated in the following Clerkship Coordinator in Surgical Education Committee activities(Required)

Check all that apply. 0.5 credits each.

Clerkship Coordinator Sub-Committee

Clerkship Coordinator mentoring program (as mentor or mentee)

Facilitating a Hot Topic, Round Table or Panel discussion at ASE Coordinator Program Track

Participate as an active member of a committee within a coordinator’s institution

Professional development: online learning modules, webcasts, etc.

Have received ASE Clerkship Coordinator Recognition Award or other awards related to the coordinator’s role

Total Credits Earned(Required)

Supporting Documents

CV/Resume, Letter of Recommendation from Clerkship Director, Reflective Essay(Required)

Please upload documents in one SINGLE PDF. Essay to be a minimum of 1 page, double spaced, 12-point Time Roman Font.

Accepted file types: pdf, Max. file size: 512 MB.

Documentation to support earned credits. Please include committee information and years, awards information, publication information, participation in programs, etc.(Required)

Accepted file types: pdf, Max. file size: 512 MB.

Power Point Presentation(Required)

Slides for any departmental, institutional, ASE or Non-ASE presentations

Drop files here or

Max. file size: 512 MB.

A photo of yourself(Required)

Max. file size: 512 MB.

Payment Information

This field is hidden when viewing the form

Application Fee(Required)

APACS Application Fee: I choose to pay a non refundable fee of $200 by CREDIT CARD.

APACS Application Fee: I choose to pay a non refundable fee of $200 by CHECK.

APACS Application Fee(Required)

Price:

Credit Card

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please email the ASE office at [email protected] once your check has been sent.

Send Check To:
ASE
11300 W. Olympic Blvd., Suite 600
Los Angeles, CA 90064

Make check payable to:
Pay to the Order Of: ASE
Memo: Academic Program Administrator Certification

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.