Residency and Fellowship Peer Reviewer Application

Applicant Information:

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* 1. Please enter your contact information:

First and last name *

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address *

Phone Number *

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* 2. Please indicate your gender identity. (Select all that apply)

Agender

Genderqueer

Gender fluid

Gender nonconforming

Intergender

Man

Non-binary

Transgender

Woman

Prefer not to answer

Prefer to self-describe

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* 3. Ethnic Origin (check all that apply)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic, Latinx, or Spanish origin

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White or Caucasian

Prefer not to answer

Prefer to self-describe

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* 4. Employment Background

Education Insitution

Education Area

Education Degree

Year of Degree

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* 5. Foreign Language Proficiencies

Foreign Language 1 and Proficiency

Foreign Language 2 and Proficiency

Other relevant proficiencies

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* 6. Availability- Pick the cycle(s) for which you are available in the upcoming academic year

Fall

Spring

Summer

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* 7. Are you available for more than one onsite review?

Yes

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* 8. What level of program have you visited in the past? (Select all that apply)

Residency

Fellowship

Not Applicable

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* 9. What level of program do you prefer this year?

Residency

Fellowship

Not Applicable

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* 10. What roles have you served in previously? (Select all that apply)

Chair

Member

Reader

Not Applicable

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* 11. Diversity, equity, and inclusion are incredibly important to the work of the CAATE. What does DEI mean to you and how does that specifically play a role in the work of being a peer reviewer?

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* 12. Describe how you will ensure diversity, equity, and inclusion are integrated into your practice, roles, and/or responsibilities as a peer reviewer.

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* 13. What are some ways that you plan on assuring diversity and diversity of thought are being evaluated while being a peer reviewer?

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* 14. Please list three references with contact information.

Reference 1

Reference 2

Reference 3

Required Uploads

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* 15. CV or resume

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

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* 16. Letter of interest for a specific position

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 17. Verification of credentialing and good standing with BOC (ATs only) and state (if applicable for ATs and other healthcare providers)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 18. Verification of NPI number

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

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* 19. Letter of recommendation which addresses the candidate's qualifications and interest in being a peer reviewer (may not be from a CAATE Commissioner or staff member)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File