EmailMe Form - ASPMN® 2019-2021 Master Faculty Application

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First Last

Academic/Professional Credentials

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

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Email *

I am interested in teaching the following course(s): *

Certification Preparation Course

Geriatric Pain Management Resource Nurse Course

Advanced Pharmacology Course

Pain 101 Course

I am a current ASPMN Member paid through 12/31/2019? *

Yes

No

I am willing to remain a member of ASPMN in good standing through 2021 should I be selected to serve as a Master Faculty member? *

Yes

No

Attach a copy of your current ANCC Pain Management Certification. *

Years of experience in pain management nursing. *

I have experience as a: *

Clinician

Educator

Researcher

Consultant

I have expertise with: *

pediatric patients

adult patients

geriatric patients

I have experience teaching audiences of 20 participants or more *

Yes

No

Briefly describe your teaching experiences. *

Narrative must be a minimum of 50 words, no more than 300 words.

I am willing to teach 1 to 2 courses per year at the regional or national level *

Yes

No

I am willing to participate in peer review of the courses that I teach *

Yes

No

I am willing to follow the format and guidelines for established content/teaching methods for the ASPMN Course(s). I agree not to add additional information and any personal commentary that may be in conflict or contrast from ASPMN information. *

Yes

No

I am willing to assist with course revisions and updates as needed *

Yes

No

Briefly describe your experience and expertise with pediatric, adult and/or geriatric patients with pain. *

Narrative must be a minimum of 25 words, no more than 1000 words.

Attach a copy of your current CV *

Reference #1 *

First Last

Please list references familiar with your teaching ability.

Reference #1 Email *

Reference #1 Phone *

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Reference #2 *

First Last

Please list references familiar with your teaching ability.

Reference #2 Email *

Reference #2 Phone *

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Reference #3 *

First Last

Please list references familiar with your teaching ability.

Reference #3 Email *

Reference #3 Phone *

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