2017 House of Delegates Candidate Information Form - Self Nomination Form

Directions

If you are interested in becoming a candidate for election to the CAP House of Delegates, please complete this form by Friday, September 30, 2016. Contact Leah Noparstak (800-323-4040 ext. 7438 or lnopars@cap.org) if you have questions.

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* 1. Professional Profile

Full Name (w/credentials): *

Job Title (w/Department if applicable): *

Employer Name: *

Employer Address: *

Employer City: *

State/Province: *

ZIP/Postal Code *

Country

Work Email Address: *

Work Phone Number: *

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* 2. Does the group own its own histology lab?

Yes

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* 3. Are you a laboratory medical director?

Yes

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* 4. Do you oversee a clinical laboratory department

Yes

If Yes, which one(s)

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* 5. Which of the following best describes your primary laboratory or practice setting (select only one)?

Academic Medical Center (with ACGME pathology residency training program)

For Profit Hospital

Not for Profit Hospital

Pathologist-Owned Laboratory

Corporate Reference Laboratory

Niche Sub-Specialty Reference Laboratory

Physician Office Laboratory (non-pathologist owned)

Non-hospital lab of Military/Federal Government

Other (please specify)

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* 6. Which of the following best describes your primary practice type (select only one)?

Academic Practice Plan

Hospital Employee

Stand-Alone Laboratory Employee

Pathologist Owned Group

Hematopathology

Industry Laboratory

Cytopathology

Other (please specify)

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* 7. Which pathology subspecialties are you involved with (select all that apply)?

Autopsy

Bone & Soft Tissue

Breast

Chemistry

Coagulation

Cytogenetics

Cytopathology

Dermatopathology

Forensic

Gastrointestinal/Liver

Genitourinary

Gynecological

Head & Neck

Hematopathology

Informatics

Industry

Microbiology

Molecular

Neuropathology

Pediatric

Pulmonary

Renal

Transfusion Medicine

Other (please specify)

Outside Professional Involvement

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* 8. Are you currently a member of your State Pathology Society?

Yes

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* 9. Please list any other medical society or association that you belong to:

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* 10. Please list if you have been actively involved in leadership positions, served on committees, acted as an advisor, or volunteered in other ways in any other medical organizations or within the CAP.

Example:
President Elect Texas Society of Pathologists 2014-2015
CMPD Council Chair College of American Pathologists 2015-2016

10.

Candidate Position Statement

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* 11. Please provide a short statement of 50 words or less that explains why you are interested in being a delegate for the CAP House of Delegates.

Delegates to the CAP House of Delegates hold an important position within the CAP. Delegates are the most passionate and engaged members. With that, delegates are expected to be involved with the House of Delegates by attending meetings, responding to surveys, participating in Action Groups, and being role models. By submitting this form you are stating your willingness to fulfill the role of delegate.