EmailMeForm
FAEMS™ 2019 - Physician
Fellowship of the Academy of EMS™
We are pleased that you are interested in NAEMSP®'s FAEMS™ designation. Please answer the following questions noting response word limitations.
Upon completion and submission of this application, you will need to pay its fee by logging in to the NAEMSP members only area of the website. Further instructions will follow upon submission.
Please note that CV's do not qualify as supporting documentation and we request that they not be submitted in support of your application.
Full Name (include medical credentials)
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Organization (if any):
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Address
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City, State Zip
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Phone:
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Email
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REQUIREMENT 1 - My NAEMSP membership ID is:
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Word Limit: 20
REQUIREMENT 2 - I am board certified as of (date):
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Word Limit: 20
REQUIREMENT 3 - I serve/have served for at least two years actively involved in EMS Medicine as a Medical Director or Associate/Assistant Medical Director, exclusive of training (YES/NO).
A personally written letter of attestation on your company letterhead fulfills this requirement.
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Word Limit: 200
REQUIREMENT 4a - Contributions to the Association – Committee, Chapter or other specific activities (YES/NO). Please indicate the manner in which you serve NAEMSP.
[300 word limit]
Examples of substantial contributions to the association may include but are not limited to:
• Chair or co-chair an NAEMSP committee;
• Produce work for a committee;
• Work as a part of a task force or work group;
• Contribution to an ad hoc committee
• Hold a position on the PEC journal's editorial board;
• Leadership or work of a local/regional NAEMSP chapter organization or related council;
• Work on special projects supported by NAEMSP, and
• Work on grants awarded to NAEMSP.
[A letter of attestation by the chapter president or chapter executive director must be attached to this application.]
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Word Limit: 300
REQUIREMENT 4b - Contributions to Specialty Practice
Please indicate which of the following in which you are actively involved, and how.
[300 word limit]
• Local, regional, or state EMS committee, council, or group;
• Administrative or departmental affairs involving matters, issues, or incidents pertaining to EMS;
• Member of a national body involved in the provision of education, evaluation, or accreditation for EMS systems or services such as, both not limited to, CECBEMS, CoAEMSP, CAAHEP, NAEMSE, or NASEMSO;
• Operational physician for a ground ambulance, air ambulance, law enforcement, fire department, US&R, HazMat, or other specialty team requiring medical oversight.
[A letter of attestation written by colleague on appropriate letterhead attached to this application must confirm your response in fulfilling at least one of the above criteria.]
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Word Limit: 300
REQUIREMENT 4c - Contributions to Specialty Advancement and Development
Please indicate which of the following in which you are actively involved and how.
[300 word limit]
• Formal teaching of EMS Medicine to physicians, nurses, medical students, out-of-hospital care personnel, or the public;
• Research and publication in the practice of provision of EMS Medicine;
• Examiner for, director of, or involvement in test development and/or administration for the American Board of Emergency Medicine (EMS Medicine) or the National Registry of Emergency Medical Technicians (NREMT);
• Reviewer for, editor of or listed author of a published scientific article or reference material in the field of emergency medical services in a recognized journal or book.
[A letter of attestation written by colleague on appropriate letterhead, or a cited publication list attached to this application must confirm your response in fulfilling at least one of the above criteria.]
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Word Limit: 300
By submitting this application, I attest that:
My NAEMSP membership is currently in good standing; that I am certified in EMS Medicine at the time of election by ABEM or AOBEM, that I fulfill the requirements as outlined above, and that I am attaching all letters of attestation.
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Yes
Date
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Upload letter of attestation for Requirement 3
Add File
Personally-written letter of attestation verifying your medical director service on company letterhead.
Upload letter of attestation for Requirement 4a
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Add File
Contributions to the Association (chapter or committee participation)
Upload letter of attestation for Requirement 4b
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Add File
Contributions the Specialty Practice (must be on appropriate organization letterhead)
Upload letter of attestation here for Requirement 4c
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Add File
Contributions to Specialty Advancement and Development (on organization letterhead, or provide publication list)
