APACS Re-certification Application - The Association for Surgical Education

Contact Information
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Institution
Institution Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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Please confirm the following:*
You must meet all of the below criteria to eligible for re-certification.
- I am an ASE member in good standing
- I have three consecutive years of experience in undergraduate surgical education administration since certification or last recertification
- I have served for at least 1 year as an active member and/or chair of an ASE Coordinator Sub-Committee
- I have presented at least 1 best practice presentation during annual ASE Coordinator Track Program
Supporting Documents
CV*
Accepted file types: pdf, Max. file size: 512 MB.
Reflective essay*
Please upload a one-page reflective essay about an experience demonstrating continued professional growth.
Accepted file types: pdf, Max. file size: 512 MB.
Powerpoint Presentation*
Best practice presentation(s) during annual ASE Coordinator Track Program
Drop files here or

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

Years served as a Clerkship Coordinator

2 credits earned per year as Clerkship Coordinator, 6 credits maximum. List each year as a Clerkship Coordinator, and click the + button to add years.

1 credit for each presentation given during the annual ASE Coordinator Program Track

1 credit per presentation (at least one presentation required). Please list year and title of the presentation. Click the + button to add year and presentation.

Please select any of the following which you have completed:
1 credit each
- ASE Coordinator Executive Committee Member
- ASE Coordinator Sub-Committee Chair
- Held a leadership role on a committee within coordinator’s institution
- Accepted abstracts for Poster or Paper Presentation
- Published Educational Research Articles

Years attended Coordinator Track Program Annual Meeting

1 credit per year attended, maximum of 3 credits. Click the + button to add years.

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

1 credit per presentation, maximum of 3 credits. Click the + button to add presentations.

Professional development: attend qualifying workshops or seminars

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

Please select any of the following which you have completed
0.5 credits each
- Active participation in a clerkship coordinator sub-committee
- Active participation in the 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.
- ASE Clerkship Coordinator Recognition Award or other awards related to the coordinator’s role
- Participation in a LCME site visit or internal review
Payment Information
Select payment method.*
- APACS Recertification Fee: I choose to pay a non refundable fee of $100 by CREDIT CARD
- APACS Recertification Fee: I choose to pay a non refundable fee of $100 by CHECK
Billing Address*
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 Re-Certification
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Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Information

Supporting Documents

Credits

Payment Information