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Anticoagulation Forum Volunteer Survey
Thank you for your interest in volunteering with the Anticoagulation Forum. Please take a moment to answer the questions below and we will be in touch if an opportunity to work together arises. We truly appreciate your time and dedication!
*
1.
Contact Information
(Required.)
First Name
Last Name
Degree(s)
# of years in practice
Preferred Email
Phone
Country of Residence
Institution
Current Role at your Institution
2.
What language(s) do you speak?
*
3.
What is your discipline?
(Required.)
Advanced Practice Provider (PA, NP)
Nurse
Pharmacist
Physician
Other, please specify
*
4.
What is your practice setting?
(Required.)
Inpatient
Outpatient
Both
*
5.
What is your specialty area?
(Required.)
*
6.
What are your areas of clinical expertise? Select all that apply
(Required.)
Anesthesiology
Cardiology, electrophysiology
Cardiology, general
Cardiology, interventional
Critical care
Drug management, anticoagulant reversal
Drug management, DOACs
Drug management, injectable anticoagulants
Drug management, VKAs
Emergency medicine
Family medicine/primary care
Gastroenterology
Gerontology
Hematology
Internal medicine
LAAODs
Laboratory
LVADs
Neurology
Oncology
Periprocedural management
Surgery, cardiothoracic
Surgery, orthopedic
Surgery, other
Valves
Vascular medicine
Other (please specify)
*
7.
What are your strengths? Select all that apply
(Required.)
Education
Fund raising
Grant writing
Health system administration
Informatics
Insurance/billing
Leadership
Organizational management
People management
Public health/policy
Other (please specify)
*
8.
Our
resources
are categorized into the following Clinical Scenarios, Disease States, Special Populations, and Quality Improvement Initiatives. Please select all that you have strong experience with:
(Required.)
Bleeding Management
Care Transitions
Device Management
Drug Information
Health Disparities
Heparin-Induced Thrombocytopenia (HIT)
Patient & Family Education
Pediatrics
Periprocedural
Women's Health
Acute Coronary Syndrome (ACS)
Atrial Fibrillation (AFib)
Ischemic Stroke
Peripheral Arterial Disease (PAD)
Thrombophilia
Valves
VTE
Antithrombotic Stewardship
Comprehensive Tools/Resources
Service Operational Performance
None of the above
*
9.
Have you previously used any of the following AC Forum resources or attended any of the following events?
(Required.)
Antithrombotic Clinical Guidance (Previously known as "Rapid Resources")
Antithrombotic Literature Updates (Previously known as "Rapid Recaps")
Literature Library
Premium Content
Boot Camp
Conference
Webinar
Other (please specify)
None of the above
*
10.
Are you a Certified Antithrombotic Care Provider (CACP)?
The
CACP
credential demonstrates specialized knowledge and skills in antithrombotic therapy, and we value this expertise within our volunteer community, however, it is not a requirement for volunteer opportunities.
(Required.)
Yes
No
Currently pursuing CACP
*
11.
How much time on a monthly basis are you willing to provide to AC Forum
(Required.)
1-2 hours
3-5 hours
5+
Other, please specify
12.
Please list any initiatives or committees you serve on within your institution (e.g., Anticoagulation Stewardship P&T/Formulary, Quality, Risk Management, Safety)
13.
Please list any external organizations where you serve in a formal capacity (e.g., board member, committee lead, officer) along with your role
14.
Did someone recommend you to us? If so, who?
15.
We always value fresh perspectives! Are there any topics, gaps, or resources you think we’re currently missing or could improve upon?
16.
Optional: You are welcome to share your race and/or ethnicity
*
17.
Upload your resume or CV
(Required.)
Choose File
No file chosen
18.
Anything else you'd like to share about why you're interested in volunteering with us? (Interests, skills, etc)
As opportunities arise, we will review submissions to determine where there may be a strong fit. Volunteer opportunities with AC Forum vary, may not be available immediately, and are not guaranteed. We appreciate your time & effort!
