Hospital Staff Membership (HSM) Designation Application

1. National Register HSM Applicant Questionnaire

25% of survey complete.

The HSM designation is an additional element appearing on your Registrant profile that highlights your unique qualifications as a psychologist. To add your hospital staff membership/privileges, your primary responsibility within the scope of your privileges must be patient care, as opposed to teaching, research, or administrative responsibilities. This questionnaire will examine the scope of privileges that you have been granted and the level of supervision required at each level of privileging. It also examines the placement of your appointment within the facility's staff structure.

To add your hospital staff membership/privileges to your National Register profile, please complete and submit this questionnaire. Please complete a separate questionnaire for each appointment.

Completing this questionnaire satisfies the National Register's verification by attestation requirement for publishing hospital staff membership.

Your published listing will appear as:

Hospital Privileges
● Hospital Name, City, State

Question Title

1. Registrant Data

Your First Name:

Your Last Name:

Your Degree (e.g., Ph.D., Psy.D., Ed.D.):

Question Title

2. Hospital/Facility To Be Added to HSM Designation in Registrant Profile

Name of Hospital/Facility:

City:

State/Province:

Question Title

3. Is this Hospital/Facility

Public

Private

Non-Profit/Not for Profit

Question Title

4. Type of Facility

General Medical/Surgical

Specialized Psychiatric or Substance Abuse Hospital

Military Facility

Rehabilitation Facility

Other (please specify)