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Education & Groups
American Board of Applied Toxicology (ABAT)
ABAT Exceptional Service Award
ABAT Newsletter
Sitting for the American Board of Applied Toxicology Exam
ABAT Examination Study Guide
Certification Renewal Documents
Life Long Learning Articles (LLSA)
ABAT Member Directory
Diplomate Verification
ABAT Board of Directors Contact Information
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Advanced Hazmat Life Support Training
MMTI Fundamentals for Front-Line Practitioners Training
TOXISMO Society for the Discussion of Scientific Literature
ToxNow
Webinars
ABAT Journal Club Webinars
COVID Webinar Series
Toxicology Residency & Fellowship Training Programs
Clinical Toxicology Guidelines Collaborative
Recommendations
Fellows of AACT
ToxCoach Mentorship Program
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Sections
Acute & Intensive Care
Addiction Toxicology Section
Clinical Toxicology In Sports
Diversity, Equity, and Inclusion Section
Herbs & Dietary Supplements
Geriatric Toxicology
Occupational / Environmental
Envenomations
Forensic
Pediatric
Weapons of Mass Destruction
Toxicology History
Radiation
Trainee and Student
Student Chapters
NACCT Annual Meeting
General Information Post-Conference
Sponsors
After the Fact CE
Research Grants
AACT Research Award
AACT Knowledge Translation Grant Award
Junior Investigator Research Grant
Gary S. Wasserman, DO, FAACT Memorial Pediatric Abstract Award
Toxicology Trainee Research Grant
Student and Trainee Travel Award
Lampe-Kunkel Memorial Award
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AACT Mobile App
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AACTion
Abstracts
Clinical Toxicology Journal
Question of the Day
News
Current Awareness in Clinical Toxicology
Toxicology Today
Out of Hospital Guidelines
Toxicology Information
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AACT Fellowship Application
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AACT Fellowship Application
Fellow of the AACT Application
This is the application for Designation as a Fellow of the American Academy of Clinical Toxicology. Deadline to submit application is June 1.
Step
1
of
5
20%
Applicant's Name
*
First
Last
Date
*
MM slash DD slash YYYY
All Letters Must Be Emailed to alyssa@clintox.org with the Name of the FAACT Applicant in the Subject Line.
Name of AACT Fellow submitting the Nomination Letter
*
First
Last
Email address of AACT Fellow submitting Nomination Letter
*
Name of AACT Fellow submitting a Letter of Recommendation (LoR) One
*
First
Last
Email address of AACT Fellow submitting a Letter of Recommendation (LoR) One
*
Name of AACT Member or Fellow submitting a Letter of Recommendation (LoR) Two
*
First
Last
Email address of AACT Member or Fellow submitting a Letter of Recommendation (LoR) Two
*
Contact Information for Applicant
Preferred Address for Contact
*
Business
Home
Business Address
*
Home Address
*
Email Address
*
Phone
*
First Year of membership in AACT
*
List all years of AACT membership (clearly indicating any gaps)
Service to AACT Core Functions
AACT Board of Trustees Member
*
Yes
No
Dates of Term
*
AACT Committee Chair
*
Yes
No
List name(s) of Committee and Dates of Service
*
AACT Committee Member
*
Yes
No
List name(s) of Committee and Dates of Service
*
List names of Committees and dates of service along with your contribution to each committee
Are you a Diplomate of ABAT?
*
Yes
No
ABAT President
*
Yes
No
Dates of Term
*
ABAT Board Member
*
Yes
No
Dates of Term(s)
*
ABAT Committee Chair
*
Yes
No
List name(s) of committees and dates of services
*
ABAT Committee Member
*
Yes
No
Names and dates of Committees and contribution to each
*
AACT Section Chair
*
Yes
No
Name of Section and dates of service
*
AACT Section Member
*
Yes
No
Dates of Section Membership and Contribution(s) to each Section
*
AACTion Newsletter Editor
*
Yes
No
Dates of Service as AACTion Editor
*
AACTion Editorial Staff
*
Yes
No
Role as Editorial Staff and Dates of Service
*
Have you contributed to AACTion?
*
Yes
No
List specific topics and dates or type of contribution
*
AACT Pre-Meeting Symposium Chair or Organizer at NACCT
*
Yes
No
Name and Date(s) of each symposium
*
AACT Pre-Meeting Symposium Speaker
*
Yes
No
Provide name and date(s) of each lecture or presentation
*
AACT Symposium (during NACCT) chair or organizer
*
Yes
No
Provide name and date(s) of each symposium
*
AACT Symposium (during NACCT) Speaker
*
Yes
No
Provide Name and Date(s) of each lecture or presentation
*
NACCT Abstract Committee Chair
*
Yes
No
List each year served
*
NACCT Abstract Reviewer
*
Yes
No
List each year served
*
Service Contribution to EAPCCT?
*
Yes
No
Service to EAPCCT Boards or Committees
*
List service to EAPCCT including position(s), date(s) of service, and description of your contributions to each committee
EAPCCT Invited Speaker
*
Yes
No
Provide name and date(s) of each lecture or presentation
*
Have you served as Editor of Clinical Toxicology
*
Yes
No
List dates of service
*
Have you served on the Editorial Board for Clinical Toxicology
*
Yes
No
List dates of service
*
Have you served as a reviewer for Clinical Toxicology
*
Yes
No
List each year served
*
Other Service to AACT
*
Describe any other service to AACT. Include date(s) of service and your role
Participation in AACT Sponsored Activity
*
Describe any participation in AACT sponsored activity or as an AACT representative of another groups activity (eg: Choosing Wisely; EXTRIP; Lipid Workgroup; etc). Be specific and include date(s) of service.
Service to the Field of Clinical Toxicology
NACCT Participation
*
a. List names and dates of any participation in ACMT, AAPCC, EAPCCT or other symposia associated with NACCT b. List dates and titles of all platform and poster presentations c. List name of meeting (NACCT, EAPCCT or other toxicology meeting) and year attended
Teaching
*
Describe your participation for teaching. Be sure to list all of your: a. academic appointments b. if you are a toxicology fellowship director or faculty for toxicology fellowship program c. Any toxicology education for residency and student training d. Any didactic toxicology lectures provided e. Any teaching awards received
Scholarship
*
Describe your participation for scholarly activity (describe toxicology-related activities only) Be sure to include: a. Publications in Clinical Toxicology (other than NACCT presentations listed above) b. Other peer reviewed publications c. Textbook chapters d. Meeting abstracts e. Grants related to toxicology f. Date and location of toxicology fellowship g. Board certification in medical or clinical toxicology (provide dates certified/recertified)
Service
*
Describe your service as it relates to toxicology Be sure to include: a. If you are a poison center director or medical director b. Any poison center contributions c. AAPCC, ACMT, SOT or other toxicology organization participation d. Toxicology-related activities to other organizations (eg: ACEP; AAP; ACCP etc) e. Community based toxicology service f. Service to state or federal government g. Editorial board, reviewer or other service to journals other than Clinical Toxicology
Active toxicology practice for four or more years
*
Yes
No
Clinical Practice
*
Briefly describe your clinical practice
Any other activities
*
Describe any other activities or service to the field of clinical toxicology not previously listed
Upload your CV here
*
Max. file size: 128 MB.
Upload your letter of recommendation here
Max. file size: 128 MB.
Upload your Nomination letter here
Max. file size: 128 MB.
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