ABAT Credentialing Application

Instructions:

Please complete all applicable sections of this application before submission.
Upload all supporting documents under each pertinent section(s) of the ABAT Credentialing Application.
Completed and electronically signed applications will be submitted to the Chair of ABAT’s Credentialing Committee.
Due Dates: A completed version of this application (PDF or online submission) is due by July 1 for applicants completing a clinical toxicology training program under the direction of a DABAT or FAACT. A completed version of this application (PDF or online submission) is due by March 1 for all other interested applicants.
Fees: An application fee of $200 must be received within 10 days of receipt of your application. ABAT Exam Credentialing Application fee can be made online by clicking here. If credentialing is denied for any reason, the $200 application fee is nonrefundable. Upon application approval, you will be contacted by the Chair of ABAT’s Credentialing Committee for the $300 examination fee payment instructions.

Step 1 of 13

Name
First Last
Preferred Email
Enter Email Confirm Email
Preferred Mailing Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
By signing below, I certify that the information provided in this application and any and all supporting material submitted is accurate and that all items have been completed as listed.
For Clinical Toxicology Post-Graduate Training Program Directors
By signing below, I certify that the information provided in this application is accurate and all items have been completed as listed.

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1. Education and Licensure
Graduate of an accredited college or university with at least a bachelor’s degree in a biomedical discipline
List: Degree(s), University(ies), and Graduation Date(s)
Profession:
Applicant is a healthcare professional and holds a valid, unrestricted license to practice in the United States
License Number:
State:
Expiration Date:
Applicants without a requirement for licensure are exempt from this criterion. Please provide explanation if not required to hold a current license to practice:

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2. Toxicology Experience
Applicants holding a master’s or doctoral degree are required to have a minimum of 2 years of full-time experience in clinical toxicology or an equivalent part-time experience.

Applicants with a bachelor’s degree in a biomedical discipline must have a minimum of 5 years of full-time experience in clinical toxicology or an equivalent part time experience.

The experiential requirement could be satisfied through one of the following post-graduate training program options:

• Completion of a formal, full-time 24-month training program in clinical toxicology under the direction of a DABAT or AACT fellow.
OR
• Completion of a formal, full-time 12-month training program in clinical toxicology under the direction of a DABAT or ACCT fellow preceded by a 1-year formal training program in a related healthcare field (e.g. PGY1 pharmacy residency)
OR
• Completion of an ASHP accredited PGY2 Emergency Medicine pharmacy residency plus the equivalent of 1 year of full-time experience in clinical toxicology
OR
• Completion of an ASHP accredited PGY2 pharmacy residency other than Emergency Medicine plus the equivalent of 1.5 years of full-time experience in clinical toxicology

Equivalent part time experience

• 1 year full-time = 2 years at 50% time = 4 years at 25%. Time is based on an average 40-hour work week
• Candidates submitting poison information specialist work as part of their application must be certified by the AAPCC for a minimum of 3 years
• Scholastic coursework is not considered to be professional experience
Post-Graduate Training: 24-Month Clin. Tox. Fellowship
Provide: Institution & Location, Program Director, and Dates.
Each item on a separate line.
Post-Graduate Training: 12-Month Clin. Tox. Residency
Provide: Institution & Location, Program Director, and Dates.
Each item on a separate line.
Post-Graduate Training: ASHP Accredited PGY1 Pharmacy Residency
Provide: Institution & Location, Program Director, and Dates.
Each item on a separate line.
Post-Graduate Training: ASHP Accredited PGY2 Pharmacy Residency
Provide: Institution & Location, Program Director, Dates and Specialty.
Each item on a separate line.
Toxicology-Related Employment History
Provide the following items on a separate line:
- Position

- Employer (Institution/Facility/Department/Location)

- Tox-Related Responsibilities

- Average hrs/week on Tox

- Employment Dates
AAPCC Certified Specialist in Poison Information
- Yes
- No
If Yes then: Date of Initial Certification:
Date of Expiration for Current Certification:
Total Years of Toxicology Experience:

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3. Consultation Requirements
Please download and complete Appendix 1 and, if necessary, Appendix 2. Once completed, please upload these documents using the UPLOAD located at the bottom of this page.

Appendix 1

Appendix 2
Upload Appendix 1
Max. file size: 128 MB.
Upload Appendix 2
Max. file size: 128 MB.

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4. Didactic Teaching/Preceptorship
Provide evidence of a minimum of 5 presentations in clinical toxicology to students or residents for a cumulative total of at least 5 hours.
Didactic Teaching
Teaching could be provided to rotators on clinical rotations, as an academic course in clinical toxicology, OR as grand rounds seminars.
Provide: Lecture titles, locations, length (hr), Learners (type &. #attended), and dates.
Each item on a separate line.
Preceptorship
Please list any precepting experience (providing clinical education and overseeing care provided by) of patient care clinical learners in clinical toxicology.
Provide: Institution (University & Program), Rotation Title, Rotation Description, and dates.
Each item on a separate line.

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5. Research Protocols
Provide evidence of designing and conducting a research study in clinical toxicology. (This can include related studies such as surveillance of adverse drug events, drug interactions, etc., quality assurance activities regarding the assessment and treatment of poisoned patients, or medication use evaluations related to clinical toxicology.)
Research Protocols
Provide: Title, Role (i.e. PI, Coordinator, etc.), Brief Description of Study, IRB Approved (Y/N), and dates.
Each item on a separate line.

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6. Research Publications
Provide evidence of authoring at least one peer-reviewed publication related to research (case series or research study) in clinical toxicology (or related topic such as adverse drug events, drug interactions, etc.).
Research Publications
Provide: Citation in APA Format (https://apastyle.apa.org/) and Article Type.
Each item on a separate line.

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7. Non-Research Publications
Provide evidence of having authored at least 2 publications related to clinical toxicology that are not the result of research conducted by the applicant (e.g. book chapters, review articles, case reports, etc.).
• Four newsletter articles (or equivalent, i.e. blogs) = 1 publication.
• Newsletter articles may only be used to satisfy one of the two required publications; the other needs to be a peer-reviewed submission.
Non-Research Publications
Provide: Citation and Publication Type.
Each item on a separate line.

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8. Professional Presentations
Provide evidence of having given at least 4 presentations on clinical toxicology to other professionals (e.g. poster presentation, continuing education programs, platform presentation, grand rounds seminar, webinars, etc.)
Professional Presentations
Provide: Title, presentation type, description (& CME, CNE, or ACPE UAN # if applicable), and date.
Each item on a separate line.

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9. Editorial/Reviewer Duties
Serve as an editor, editorial board member, or peer reviewer for health care or toxicology-related publication/journal
OR
Peer reviewer for abstracts submitted to a toxicology-related conference

Other editorial/reviewer activity will be considered based on information provided by the candidate (e.g. expert witness work, Pharmacy & Therapeutics Committees, monographs for drug databases, etc.). More complete descriptions and supporting documents may be referenced here and added in Appendix 3.
Editorial/Reviewer Duties
Provide: Journal or Conference, Total Peer Reviews, and Date Range.
Each item on a separate line.
*You may enter more than one journal or conference per type of editor/reviewer category. Be sure to provide complete information for each entry.
Expert Witness
Provide: Brief description of case, your involvement and date.
Each item on a separate line.
Pharmacy & Therapeutics Committee
Provide: Brief Description of Involvement in P&T (include any MUE or drug class monographs you prepared) and date.
Each item on a separate line.
Drug Monographs for Databases
Provide: Database, brief description and date.
Each item on a separate line.
Describe other activities below:
More complete descriptions and supporting documents may be referenced here and uploaded below.
Max. file size: 128 MB.

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10. Committee Work
Demonstrate active service on at least one toxicology related committee (e.g. local, regional, or national).
• Local examples include emergency preparedness, pharmacy safety and therapeutics, quality and safety, etc.
• Active service means holding a leadership position within the committee or providing objective evidence of involvement within the group.
Committee Work
Provide: Committee, Organization, Roles & Responsibilites and Date Range.
Each item on a separate line.

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11. Community Education
Provide evidence of a minimum of 5 presentations (or other educational activity including media appearances) to the lay public on topics related to clinical toxicology.
Community Education
Provide: Topic/Presentation, Audience, Brief Description, and date.
Each item on a separate line.

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References
Reference #1 Information
Provide: First/Last name, email, phone number and mailing address.
Each item on a separate line.
Reference #2 Information
Provide: First/Last name, email, phone number and mailing address.
Each item on a separate line.
Reference #3 Information
Provide: First/Last name, email, phone number and mailing address.
Each item on a separate line.
Final Review
You have reached the end of the ABAT Credentialing application. Please make sure all sections have been addressed and that the information submitted is accurate before clicking SUBMIT below. As a reminder, an application fee of $200 must be received within 10 days of submitting of your application. ABAT Exam Credentialing Application fee can be made online by clicking here. If credentialing is denied for any reason, the $200 application fee is nonrefundable

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ABAT Credentialing Application

ABAT Credentialing Application

Step 1 of 13

1. Education and Licensure

2. Toxicology Experience

3. Consultation Requirements

4. Didactic Teaching/Preceptorship

5. Research Protocols

6. Research Publications

7. Non-Research Publications

8. Professional Presentations

9. Editorial/Reviewer Duties

10. Committee Work

11. Community Education

References

Final Review

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