PHA-Accredited PH Care CentersPage 1 of 3

Oversight Committee Application

PHA-Accredited Pulmonary Hypertension Care Centers

Oversight Committee Application

Application Face Sheet Information
Instructions: Click on the highlighted field to type in your information. Check boxes can be clicked to check off the appropriate answer.
Name: / Click here to enter text. /
Title: / Click here to enter text. /
Academic Rank: / Click here to enter text.
Home Institution: / Click here to enter text. /
Mailing Address
(as of October 2016): / Click here to enter text. /
Phone: / Click here to enter text. /
Email: / Click here to enter text. /
Assistant’s Name: / Click here to enter text. /
Assistant’s Phone: / Click here to enter text. /
Assistant’s Email / Click here to enter text. /
PH Experience
Years of Experience in PH (excluding training): / Click here to enter text. /
Current involvement in PH / Click here to enter text. /
% of an average week spent on PHclinicalactivities
% of an average week spent on PH research activities / Click here to enter text.
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Anticipated changes in applicant’s workload or duties in the next three years, if any / Click here to enter text. /
Experience with PHA
Please list all committees on which you have served (and years served) / Click here to enter text. /
Please list all organizational activities (and years performed) / Click here to enter text. /
By submitting this application, I hereby certify that the statements and information in this application are true and correct to the best of my knowledge and belief. I authorize the Pulmonary Hypertension Association to investigate all statements contained in this application form and any attachments submitted with it, unless I have stated in writing to the contrary. I agree

Please answer the following questions. Note that each question has a word limit.

1. What do you consider to be the most pressing issue or issues in the pulmonary hypertension medical community both nationally and at your specific institution and why? Please limit your response to 250 words.
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2. Describe your current involvement with the pulmonary hypertension community, giving specific attention to leadership experience. If applicable, include any organizations and affiliations of which you are an active member and any positions held. Please limit your response to 250 words.
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3. Describe your involvement over the previous five years serving on local or national committees. Please not that these committees do not necessarily need to be PH-related. If applicable, give specific attention to leadership experiences. Please limit your response to 250 words.
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4. Please describe any previous experience serving on accreditation boards, oversight or review committees.Please limit your response to 250 words.
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5. Describe any prior experience conducting site visits. Please limit your response to 250 words.
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