Continuing Certification Committee Member Application

CONTINUING CERTIFICATION COMMITTEE MEMBER APPLICATION

We’re seeking ABA diplomates to serve as members of the Continuing Certification Committee. If you are interested, please complete the application below.

DEMOGRAPHICS

First Name*	Last Name*


Email Address*

Institution/Practice Group Name*

Phone*

Street Address*


City*	State*


Zip Code*	Country*

Are you of Hispanic, Latino or Spanish origin?*

What is your race? (select all that apply)*

American Indian or Alaskan Native

Asian

Black/African American

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Other (add in field below)

Prefer not to report

If you selected "Other" in the question above, please enter your race below.

Subspecialty Certification (Choose All That Apply)

Adult Cardiac Anesthesia

Critical Care Medicine

Hospice & Palliative Medicine

Neurocritical care

Pain Medicine

Pediatric Anesthesiology

Sleep Medicine

TELL US ABOUT YOURSELF

Describe (200 words or fewer) your practice setting*

Describe (200 words or fewer) why you are interested in serving as a member of the ABA’s Continuing Certification Committee*

Describe (200 words or fewer) the skills you would bring to your role as a member of the ABA’s Continuing Certification Committee*

List current or recent roles, activities and experience that you feel are relevant to the position*

VOLUNTEER POLICIES

MOCA Participation
All volunteers are required to participate in MOCA. We’ll waive the annual $210 MOCA fee for volunteers for each year of service provided. The fee waiver will be applied in the year following the service. Volunteers maintaining more than one certificate only receive the waiver for one certificate unless they are writing for two or more exam programs.

Professional Standing
Please advise us of any and all restrictions placed on any of your medical license(s), and provide complete information about restrictions within 60 days of their imposition. If you have any medical licensure restrictions, we reserve the right to indefinitely suspend or terminate any/all of your volunteer roles (including your participation in ABA activities) until restrictions have been satisfactorily resolved.

Volunteer Code of Conduct
Volunteers serve as representatives of the ABA beyond their duties as directors, question authors, editors and examiners. Given the status of an appointment, the ABA expects volunteers to be role models of professionalism at all times, whether or not directly involved in ABA activities, and to provide timely responses to requests from the ABA. Anesthesiologists serving as ABA volunteers should provide high-quality patient care and demonstrate a commitment to life-long learning and patient safety as evidenced by participation in Maintenance of Certification in Anesthesiology. A volunteer must understand unconscious bias and its impact on assessments and should encourage constructive feedback with the ability to raise concerns without fear of retaliation. Violations of these expectations jeopardize the validity of assessments and reputation of the ABA in the eyes of the public, candidates and colleagues, and such violations may result in termination of the volunteer opportunity.

Selecting “Yes, I agree” indicates that you have read the above policies in full and agree to abide by them if you are appointed as a member of the ABA's Continuing Certification Committee*

Yes, I agree

No, I do not agree