initial application formc.ymcdn.com/.../2018_new_fellowship_applicat.pdfrevised 2017-11-21 – iacp...

Initial Application

Form

© 2017 International Academy of Compounding Pharmacists. All Rights Reserved Revised 2017-11-21 – IACP Fellowship Program – Initial Application Form 2

FellowshipApplicationQuestionnaire

1. This form must be filled out in its entirety. 2. Fellowship applicants must earn at least 100 points in order to be considered by the IACP

Fellowship Committee. 3. Letter of recommendation by current IACP Fellow. 4. Submit a video tour of practice site. 5. All applications must be submitted to IACP by May 4, 2018 or by December 3, 2018. 6. Fellowship Inductions take place twice a year at the IACP Educational Conference and

Compounders on Capitol Hill. Upon completion submit this application, letter of recommendation and video tour to:

Jennifer Petska Director, Development and Membership International Academy of Compounding Pharmacists [email protected]

If you have any questions, please contact Jennifer directly at (612) 723-3832 or via e-mail [email protected].

Applicant’sPersonalInformation Name _________________________________________________ Honorific ________________ Practice/Business Name ___________________________________________________________ Mailing Address __________________________________________________________________ City ____________________________________ State _______________ ZIP Code ___________ Telephone _____________________________ Cell/Alternate Phone ______________________ Email Address ____________________________________________________________________ Pharmacy School __________________________________________________________________ Date of Graduation _______________________ Degree Conferred __________________________

IACP Use Only Date Received ___/___/___ Interview Date ___/___/___

ApplicationInstructions


CategoryI-PharmacyAssociationMembership

National Association 2 points per year, per association for the last three years International Association 2 points per year, per association for the last three years State Association 1 point per year, per association for the last three years Local Association 1 point per year, per association for the last three years

Name of Association Years Points _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ Total Category I ___________ 15 Points Maximum CategoryII–ProfessionalMeetingAttendance

IACP Compounders on Capitol Hill 5 points per meeting per year for the last three years IACP Educational Conference 5 points per meeting per year for the last three years IACP Board Meeting (as a guest) 5 points per meeting per year for the last three years IACP Committee Meeting 5 point per meeting per year per committee IACP Telephone Conference 1 point per meeting per year for the last three years IACP Fellowship Activity 1 point per meeting per year for the last three years Other National Compounding Conference 1 point per meeting up to three points/year Other Regional Compounding Seminar 1 point per meeting up to three points/year State Association Meeting 1 point per meeting per year for the last three years State Board of Pharmacy Meeting (as a guest) 1 point per meeting per year for the last three years Local Association Meeting 0.25 point per meeting per year for the last three years

Name of Meeting Years Points _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________ _____________________________________________ _____________________ ___________

Total Category II ___________ 50 Points Maximum

AssociationInvolvement


CategoryIII–ContinuingEducation Each CE credit hour is one (1) point. CE should be 75 percent compounding related and earned in the three years prior to the application date. New Fellow applications must provide documentation of at least 75 CE hours. Include copies of your CE certificates or a print-out of your NABP CE report for each point claimed for category III. Continuing Education Hours Points ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ ________________________________________________________ __________ ___________ Total Category III ________ 50 points Maximum

ContinuingEducation


CategoryIV–PharmacyLeadership Points are per year, per position for the last three years. Note: IACP members who have served as a treasurer or president on the IACP Board of Directors have fulfilled all requirements in Category IV.

Each international level elected position 5 points/year Each national level elected position 4 points/year Each state elected position 4 points/year Each national, international, or state level appointed position 2 points/year

Organization and Position Years of Service Points ___________________________________________________ ______________ ___________ ___________________________________________________ ______________ ___________ ___________________________________________________ ______________ ___________ ___________________________________________________ ______________ ___________ ___________________________________________________ ______________ ___________ Total Category IV ___________ 25 Points Maximum CategoryV–IACPLeadership Each activity earns one point per year, per activity for the last three years. Activities include officers, board of directors, committee chairman, and positions such as acting as a state leader, serving on a committee, working an exhibit at a national conference, representing IACP in an official capacity (delegate, etc), sponsoring a fellowship applicant, etc. Please be specific when listing.

IACP Executive Committee Member 20 points IACP Board Member 5 points Committee Chairman 2 points Committee Participation 1 point

Organization and Position Years of Service Points ___________________________________________________ ______________ ___________ ___________________________________________________ ______________ ___________ ___________________________________________________ ______________ ___________ ___________________________________________________ ______________ ___________ Total Category V ___________ 25 Points Maximum

PharmacyLeadership


CategoryVI–CompoundingPublications Points are assigned based upon the type of publication and applicant involvement. Note: Attach a copy of each article to receive points.

Author or co-author of published text 7 points Author or co-author of chapter in published text 5 points Author or co-author of published article 5 points Editing chapter, article, or book 2 points A case report 2 points Creating/maintaining a professional blog 2 points Newsletter article written for your pharmacy newsletter 1 point Patient Advisory Leaflet: Compounded drug (published) 1 point

Publication Title of Article Points _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ _________________________________ ________________________________ ___________ Total Category VI ___________ 30 Points Maximum

ScholarlyActivity-Publications


CategoryVII–ProfessionalPresentations Points are assigned per presentation, per year, for the last three years. Note: Submit an outline for each presentation given in order to receive points for this category.

Presentation to health care professionals 5 points/each (such as doctors, nurses, pharmacists, etc.) Live presentation at a national/international pharmacy meeting 5 points/each Poster presentation at a professional meeting 5 points/each Volunteer Consulting 2 points/each Obtain/sponsor/facilitation of a professional speaker 2 points/each presentation (doctor, another pharmacist, etc.) Pharmacy topics presented to general public 1 point/each

Presentation Title Meeting Audience Size Points ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ ____________________________ ______________________ ____________ ___________ Total Category VII ___________ 25 Points Maximum

ScholarlyActivity-Presentations


ScholarlyActivity-Presentations

CategoryVIII–Teaching Two points per year are permitted for each compounding related course taught by the applicant. To qualify, the educational activity must be a formalized course and affiliated with a college or technical school for health care professionals or an ACPE-accredited course through a professional company or organization. This category also can consist of intern/externship/rotation programs provided by pharmacists and their pharmacy or a preceptor position with a university. For verification purposes, please provide a copy of the course syllabus and a detailed description of each listed program. Course Institution Years Points _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______ _______________________________________ ______________________ _________ _______

Total Category VIII _______ 20 Points Maximum

ScholarlyActivity-Teaching


CategoryIX–CivicService Each activity earns 1 point per activity in the last three years. Activities include positions such as participation with various charity organizations, coaching a sport, religious activities, serving in the military reserves, communicating with Board of Pharmacy, meeting with a state or elected official (outside of Compounders on Capitol Hill), etc. Activity Years Points ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________

Total Category IX ________ 10 Points Maximum

CategoryX–ProfessionalService/Relationships Each activity earns one point per activity for the last three years. A detailed description of the organization, the applicant’s role in the group, and frequency of meeting times must be presented with category X for points to be received. Points earned based on the applicant’s involvement with Boards of Pharmacy, medical groups or associations that meet on a regular basis such as a hospice team, physicians group, manager/supervisor of a pharmacy department, pharmacy owner etc. Group/Relationship Years Points ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________

Total Category X ________ 10 Points Maximum

Service–Civic&Professional

Service–Civic&Professional


PharmacyAwards

CategoryXI–PharmacyAwardsandRecognition Points are earned based upon receipt of the award with no time frame.

Awards Recognized International Pharmacy Awards 2 points National Pharmacy Awards 2 points State Pharmacy Awards 2 points Local Pharmacy Awards 2 points Other Professional Awards (university, etc.) 2 points

Group/Relationship Years Points ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________

Total Category XI ________ 20 Points Maximum


PharmacyAwards

CategoryXII–CertificatesorCertificationStatus Please attach a copy of your current certificate or certification status.

Certified Clinical Nutritionist 2 points Certified Diabetes Educator (CDE) 2 points Herbalist (Master) (Dherb) 2 points Homeopathy (DNBHE) (DLHom) (Dhom) 2 points Naturopathy (M.S.) (N.D.) 2 points Pharmacy certifications requiring renewal by exam 2 points Immunization Certificate Program 2 points Continuing Education (Patient Care) 2 point (each)

Certificate/Certification Number of CEs Points ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________ ___________________________________________________ ______________ ________

Total Category XII ________ 15 Points Maximum

ProfessionalCertifications

AdvancedTrainingandCertification


CompiledPointSummary Category Points

I Pharmacy Association Membership _____________________ 15 Points Maximum II Professional Meeting Attendance _____________________ 50 Points Maximum III Continuing Education _____________________ 50 Points Maximum IV Pharmacy Leadership _____________________ 25 Points Maximum V IACP Leadership _____________________ 25 Points Maximum VI Scholarly Activity – Compounding Publications _____________________ 30 Points Maximum VII Scholarly Activity – Professional Presentations _____________________ 25 Points Maximum VIII Scholarly Activity - Teaching _____________________ 20 Points Maximum IX Civic Service _____________________ 10 Points Maximum X Professional Service/ Relationships _____________________ 10 Points Maximum XI Pharmacy Awards _____________________ 20 Points Maximum XII Advanced Training/Certificates _____________________ 15 Points Maximum

Total Points _____________________ Total Needed: 100 points

CategoryTotals

initial application formc.ymcdn.com/.../2018_new_fellowship_applicat.pdfrevised 2017-11-21 – iacp...

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