TO:ACCME Accreditation Surveyor Applicant

TO:ACCME Accreditation Surveyor Applicant

FROM:Accreditation Council for Continuing Medical Education

RE:Surveyor Eligibility and Application

Thank you for your interest in volunteering for the ACCME as an accreditation surveyor. The role of an ACCME accreditation surveyor is of critical importance to the ACCME. A surveyor’s interaction with accredited providers helps the ACCME fulfill its mission and serves as a link between the ACCME and its accredited providers.

The ACCME has articulated criteria for surveyor eligibility and competencies for surveyors to help explain the unique knowledge and skills sets that are required to become and continue in the role of an ACCME accreditation surveyor.

On the following pages you will find information about ACCME’s expectations of applicants and practicing surveyors. Once you review these requirements, you are invited to complete and submit an application that will demonstrate your willingness and ability to meet these guidelines.

If you have questions regarding surveyor eligibility or the application review process, please contact the ACCME at .

About the ACCME Surveyor Application Form

This document is a ‘locked’ Microsoft Word® form.

You can move from fill field to fill field using ‘Enter’ or ‘Tab’.

PLEASE MAKE SURE YOU SAVE THE DOCUMENT AS YOU GO ALONG SO YOU DO NOT LOSE YOUR WORK.

The document uses:

• Text fields where you are limited to 500 words (except for contact information where you are limited to one line)
• Check boxeswhere an ‘X’ will be inserted when you select that box. Please be sure that only the boxes you mean to select are selected
• Drop-down fields where you must select one choice from a list

PLEASE COMPLETE ALL THE ELECTRONIC FIELDS.

COMPLETED APPLICATIONS SHOULD BE SUBMITTED TO:

ACCME SURVEYORAPPLICATION REVIEW

515 North State Street
Suite 1801
Chicago, Illinois
60654

or

FAX: 312 410-9026

or

ACCME® Accreditation Surveyor Application

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ACCREDITATION SURVEYOR APPLICATION

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Name:
Title:
Business Name
Business Address:
Business Telephone number:
Business Fax number:
Primary e-mail address:
Home Address
Alternate phone number:
Preferred address, phone number and email:
Section 1 / Eligibility Assessment

To be eligible to volunteer for the ACCME as an accreditation surveyor, an applicant must meet the three Criteria listed below.

Please note:An individual who isemployed by a commercial interest, as defined by the ACCME, i.e., any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, is not eligible to volunteer for the ACCME as an accreditation surveyor.

Criterion 1
CME Knowledge & Experience / Have prior knowledge within the profession of continuing medical education (CME)and a minimum of 3 years experience to includeongoing involvement* with (1) an ACCME accredited provider; or (2) a state medical society accredited provider; or (3) an ACCME recognized state medical society.
_____
*Involvement is defined as taking an active role in the development, implementation and evaluation of ongoing continuing medical educational activities as a volunteer or staff person. It may also involve the assessment of an overall program of continuing medical education. It may NOT include service as a private consultant for CME accreditation purposes. Please note: Individuals who have been employed by the ACCME within 18 months of application are not eligible for consideration.
Criterion 2
Accreditation Process Experience: / Have experience participating in a regulatory accreditation process. Examples of this experience are:
A)Participation in an ACCME accreditation or recognition review;
B)Participation in JCAHO, ACGME, or LCME review;
C)Participation in an accreditation review for an ACCME recognized state medical society.
Criterion 3
Willingness to serve as ACCME volunteer: / Demonstrate willingness to serve as a volunteer for ACCME. This includes:
A)Ability to comply with ACCME’s conflict of interest policies for surveyors.
B)Ability to meet and maintain ACCME Surveyor Competencies.
C)Participation in the ACCME surveyor training workshop designed for new surveyors.
D)Participation in an ACCME “Bridge to Quality” workshop within 12 months of submitting application (at own expense).
E)The ability to work on behalf of the ACCME as a volunteer.
The ACCME expects surveyor applicants to describe and verify, where appropriate, how they meet these criteria. Applicants have the opportunity to provide written descriptions in the application and verbal descriptions in an interview with the ACCME.
I attest that I meet ACCME’s Surveyor Eligibility Criteria.

If you are able to attest that you meet ACCME’s Surveyor Eligibility Criteria,

GO TO SECTION 2.

/ Descriptive Information
Section 2 / Please provide the requested information below in a narrative description.
Criteria 1 states that a surveyor applicant must have prior knowledge and experience within the profession of continuing medical education. / Describe your knowledge and experience within the profession of continuing medical education.
(Max 500 words)
Criteria 2 states that a surveyor applicant must have experience participating in a regulatory accreditation process. / Describe your experience participating in a regulatory accreditation process.
(Max 500 words)
Criteria 3 states that a surveyor applicant must demonstrate willingness to serve as ACCME volunteer / Describe your reasons for submitting an application for an ACCME accreditation surveyor.
(Max 500 words)

GO TO SECTION 3

/ Attachments as Verification
Section 3 / Please attach or secure the followingmaterials that demonstrate your ability to meet ACCME’s criteria for surveyor eligibility.
Criteria 1 states that a surveyor applicant must have prior knowledge and experience within the profession of continuing medical education. / Regarding Criteria 1…

• Attach a copy of your curriculum vitae.
• Secure two letters of recommendation from colleagues, at least one of who is either a) a current ACCME volunteer; b) a current volunteer or staff member of an ACCME accredited provider; or c) current volunteer or staff member of an ACCME recognized state medical society. Letters of recommendation should be sent directly and separately to the ACCME by each reference. Please note: ACCME Surveyors who have completed a survey of your organization in the last twelve months cannot offer the recommendation.

Criteria 2 states that a surveyor applicant must have experience participating in a regulatory accreditation process. / Regarding Criteria 2…

• Attach a copy of your curriculum vitae.

Please include here the names of the two colleagues who will be submitting recommendation on your behalf. The ACCME will contact you, the applicant, if ACCME does not receive the letters of recommendation within 30 days of the submission of your application. ACCME will not follow-up with individuals listed as references if their letters are not received.

Reference #1:
Name:
Title:
Address:
Telephone number:
e-mail address:
Reference #2:
Name:
Title:
Address:
Telephone number:
e-mail address:

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Before the ACCME will move forward with the surveyor application review process, your intentions, understanding, and commitment to abide by ACCME’s expectations must be confirmed.

Please read carefully each of the following confirmation statements and use an‘X’ as your attestation.

I attest I have reviewed and have the ability to maintain ACCME Surveyor Competencies. Surveyor competencies can be found on under “Volunteer Opportunities.”
I attest that I am not a private consultant on accreditation or ACCME’s accreditation process.
ACCME Volunteers shall not serve as private consultants for CME accreditation purposes to any organization or institution. Private consulting in this context means providing advice to a specific organization, for personal gain, on accreditation or ACCME’s accreditation process. Private consulting should not be confused with providing such advice without personal gain, in the course of fulfilling normal position responsibilities.
I attest that I am not employed by a commercial interest, as defined by the ACCME i.e., any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, is not eligible to volunteer for the ACCME as an accreditation surveyor.
ACCME Volunteers shall not be employed by a commercial interest, as defined by the ACCME i.e., any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
I attest that I have attended an ACCME “Bridge to Quality” Workshop in the past year or will attend a workshop (see for upcoming workshop dates).
Date of workshop attended:
OR
Date of workshop I will attend:
I attest that I will participate in a one-day surveyor training workshop designed for new surveyors, if approved as an accreditation surveyor.

Thank your for completing the surveyor application.

Please sign and submit this application to the ACCME. You may submit the application via mail, fax, or email. If via email, please provide an electronic signature. Your application will be considered complete once the ACCME receives the letters of recommendation from your two references.

Name of applicant:
Signature of applicant: / Date: / mm/dd/yyyy

ACCME® Accreditation Surveyor Application

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