2018 AAP Grand Rounds Editorial Fellowship Application Click here for the job description (PDF).Appointments are made on the basis of knowledge, expertise, and interest. Question Title * 1. Name Question Title * 2. Specialty Area Question Title * 3. AAP District Question Title * 4. Institution Name and Address Institution Name Street Address City State Zip Code Phone Email Question Title * 5. Home Address Street Address City State Zip Code Phone Question Title * 6. Education Medical School Year of Graduation Question Title * 7. Gender Question Title * 8. AAP Membership Current Yes No Question Title * 9. AAP Member ID Question Title * 10. Present Position:Please indicate the average number of hours/week spent in each of the 5 designated activities listed below: Practice Involving the Direct Care of Patients, both inpatient and outpatient care:(Exclude teaching, training, research and include time spent on record keeping and other office/administrative work) Administration other than own practice:(Include activities related to planning or management of services in hospitals or other health facility/agency, or as a salaried administrative staff member or executive of an organization) Medical Teaching(Include hours spent in teaching/training/writing scientific materials for professional publications, preparation in your office, hospital, educational institutions) Medical Research(Funded or unfunded, performed in your office or elsewhere) Other Medical Activities NOT Involving the Direct Care of Patients(such as IRB, credentialing, CME participation, volunteer work, community services, etc) Question Title * 11. How will your interests and expertise serve to complement the editorial/advisory board? Question Title * 12. Describe your activities in AAP State Chapters or National Committees/Sections. Question Title * 13. Are you a member of your AAP State Chapter? Yes No Question Title * 14. Are you a current member on any other editorial board (including AAP publications) or the American Board of Pediatrics? Yes No If yes, please specify which board and the dates of your term(s) on the board: Question Title * 15. Community activities (ie, school board, health department, Head Start, health centers, community planning, regional medical programs, etc): Question Title * 16. Please upload your CV in PDF or Doc/Docx format. PDF, DOCX, DOC file types only. Choose File Choose File No file chosen Remove File Please upload your CV in PDF or Doc/Docx format. Please Note: You will receive an email containing a link to an electronic disclosure form. The disclosure must be completed and submitted to be considered for an editorial/advisory board position. Question Title * 17. CERTIFICATION STATEMENTI certify that the information provided in this application, in my CV, and in any other attachments hereto, is true and complete to the best of my knowledge. I understand that the AAP will rely on this information in making a decision regarding this editorial board appointment. The AAP treats all nomination materials as confidential. Applications, CVs, and other documents will be kept secure and will not be shared with anyone except designated AAP staff and the editorial leadership.I understand that completion of this form in no way implies an appointment to this editorial/advisory board. I acknowledge that, if appointed, I must remain a member in good standing of the AAP. I further acknowledge that, if appointed, I will promptly and fully disclose any changes or potential new conflicts of interest that may affect my ability to impartially serve as a member of this editorial/advisory board. I understand that accepting this certification statement carries the same force as a signature.Please check: I accept Please verify your Name, Date, and AAP ID. DEADLINE FOR RECEIPT OF NOMINATION MATERIALS FOR THE AAP Grand Rounds POSITION IS 4:30 PM CST FRIDAY, SEPTEMBER 14, 2018Email questions to: Kate Larson, senior managing editor, at klarson@aap.org. Done
