2026 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 8 12% 2026 Fellow of AACT Application Thank you for your interest in applying to become a Fellow of AACT. There are two main sections to the application, with subsections under each: AACT Core Functions AACT Contributions/Activities AACT Affiliate Activites NACCT Contributions Other Sustained Contributions to Toxicology Sister Society /Medical Society Contributions/Activities Other Sustained Toxicology Related Contributions/Activities Applicaiton Scoring Guidelines include, but are not limited to: Minimum of 20 points are needed on your application to be considered, with at least 15 of the 20 points coming from Section 1: AACT Core Function. Points alone do not guarantee fellowship acceptance. Assigned Points and Maximum Points per question/section will be listed in the application. Broad Participation in AACT is required with 3+ different areas necessary Ongoing service to AACT is expected with sustainable activities seen on application Service/Active Participation on committees and sections will be verified by Chair of the respective committee or section (membership alone is not enough for points) Application Submission Date* MM slash DD slash YYYY Applicant's Name* First Last Credentials Recommendation LettersIn order for the application to be complete, applicants must receive three letters of recommendation, with at least two from current Fellows of AACT. The individuals you list below will automatically be contacted with instructions and the deadline to submit your recommendation letters. Letter of Recommendation #1:*Name and email address of the Individual/Fellow of AACT who is submitting a recommendation letter on your behalf. First Last LOR 1: Email Address for the Individual/Fellow of AACT who submitting a recommendation letter on your behalf* Letter of Recommendation #2:*Name and email address of the Individual/Fellow of AACT who is submitting a recommendation letter on your behalf. First Last LOR 2: Email Address for the Individual/Fellow of AACT who submitting a recommendation letter on your behalf* Letter of Recommendation #3:*Name and email address of the Individual/Fellow of AACT who is submitting a recommendation letter on your behalf. First Last LOR 3: Email Address for the Individual/Fellow of AACT who submitting a recommendation letter on your behalf* Contact Information for ApplicantPreferred Address for Contact*Please SelectBusinessHomeBusiness Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address* Phone*Have you held an Active Full AACT Membership since July 2021?*Assigned Points: 1 pt | Max Points: 1 | Membership years in a category other than a Full Member do not count towards the minimum years of eligibility. Yes No First Year of membership in AACT*List all years of AACT membership (clearly indicating any gaps) Section 1: AACT Core Functions Ongoing contributions to AACT Core Functions are a key part of the fellow application. At least 15 of the 20 points must come from this section of the application. Section 1. AACT Core Functions is separated into three subsections: 1.1: AACT Contributions/Activities 1.2: AACT Affiliate Activities 1.3: NACCT ContributionsSubsection 1.1: AACT ContributionsAACT Officer/Executive Committee*Assigned Points: 3 pts/year | Max Points: 9Please SelectNoYesRole and Dates of Term*AACT Board of Trustees Member*Assigned Points: 3 pts/year | Max Points: 9Please SelectNoYesRole and Dates of Term*AACT Committee Chair/ABAT Advisory Board Chair*Assigned Points: 3 pts/year | Max Points: 9Please SelectNoYesList name(s) of Committee and Dates of Service*AACT Committee Member/ABAT Advisory Board Member*Assigned Points: 2 pts/year | Max Points: 6Please SelectNoYesList name(s) of Committee and Dates of Service*List names of Committees and dates of service along with your contribution to each committeeAACT Section Chair/ABAT Subcommittee Chair*Assigned Points: 2 pts/year | Max Points: 6Please SelectNoYesName of Section/ABAT Subcommittee and Dates of ServiceAACT Section Member/ABAT Subcommittee Member with Active Participation*Assigned Points: 1 pts/year | Max Points: 3Please SelectNoYesDates of Section Membership/ABAT Committee Membership and Contribution(s) to each*AACT/ABAT Webinar/Journal Club Organizer*Assigned Points: 2 pts/year | Max Points: 6Please SelectNoYesDate, Section and Webinar Title*AACT/ABAT Webinar/Journal Club Presenter*Assigned Points: 2 pts/year | Max Points: 6Please SelectNoYesDate, Section or Webinar Title, and Presentation Title*AACT Sponsored Activity Chair (i.e. Work Group or Research Seminar)*Assigned Points: 3 pts/year | Max Points: 6Please SelectNoYesDates of Service and Activities*Describe any other AACT Sponsored Activities that you chaired. AACT Sponsored Symposium Organizer/Chair at Sister Society Meeting*Assigned Points: 4 pts/year | Max Points: 8Please SelectNoYesDates of Service and Activities*Describe AACT Sponsored Symposiums that you chaired/organized at Sister Society Meetings. AACT Sponsored Symposium Speaker/Moderator at Sister Society Meeting*Assigned Points: 3 pts/year | Max Points: 6Please SelectNoYesDates of Service and Activities*Describe AACT Sponsored Symposiums that you chaired/organized at Sister Society Meetings. AACT Sister Society Liaison/Regional Representative*Assigned Points: 2 pts/year | Max Points: 4Please SelectNoYesProvide years of service and describe activity*Have you served as an AACT Tox Coach Program Mentor?*Assigned Points: 3 pts/year | Max Points: 6Please SelectNoYesProvide Years of Service*AACT Questions of the Day Writer (minumum of 5 questions/year to qualify)*Assigned Points: 1 pts/year | Max Points: 3Please SelectNoYesProvide number of questions/year*AACT Newsletter Editor*Assigned Points: 4 pts/year | Max Points: 8Please SelectNoYesProvide the years and number of issues published under your role as editor.*AACT Newsletter Editorial Staff*Assigned Points: 3 pts/year | Max Points: 6Please SelectNoYesProvide the years and number of issues published during your service as editorial staff*AACT Newsletter Section Submissions*Assigned Points: 1 pts/submission | Max Points: 4Please SelectNoYesProvide the Title, Year and Month of the Newsletter Issues containing your submission.*Did you serve as chair or organizer for any other AACT Sponsored Activity?*Assigned Points: 3 pts/activity | Max Points: 9Please SelectNoYesPlease provide the date and description of the activity*Did you present at or moderate any other AACT Sponsored Activity?*Assigned Points: 2 pts/activity | Max Points: 6Please SelectNoYesPlease provide the title, date and description of the presentation* Subsection 1.2: AACT Affiliate ActivitiesHave you served as Editor or Senior Editor of the Clinical Toxicology Journal?*Assigned Points: 4 pts/year | Max Points: 12Please SelectNoYesProvide Years of Service*Have you served on the Editorial Board for Clinical Toxicology?*Assigned Points: 3 pts/year | Max Points: 9Please SelectNoYesProvide Dates of Service*Have you served as a reviewer for Clinical Toxicology*Assigned Points: 1 pts/year | Max Points: 4Please SelectNoYesProvide Years of Service and Average Number of Reviews per Year.*Publications in Clinical Toxicology Journal?*Assigned Points: 2 pts/publications | Max Points: 8Please SelectNoYesList the dates and titles of your publications*Have you served as a member of the Advanced Hazmat Life Support Scientific Advisory Committee*Assigned Points: 1 pts/year | Max Points: 4Please SelectNoYesProvide Years of Service*Have you served as an Advanced Hazmat Life Support Instructor*Assigned Points: 0.5 pts/class | Max Points: 4Please SelectNoYesProvide the dates and location of each class*Have you served as an Advanced Hazmat Life Support Content Creator/Textbook Author?*Assigned Points: 1 pt/chapter | Max Points: 6Please SelectNoYesList the number of chapters, titles and textbooks that you have authored or co-authored* Subsection 1.3: NACCT ContributionsAACT Pre-Meeting Symposium Chair or Organizer at NACCT*Assigned Points: 4 pts/symposium | Max Points: 8Please SelectNoYesName and Date(s) of each symposium*AACT Pre-Meeting Symposium Speaker at NACCT*Assigned Points: 3 pts/lecture | Max Points: 6Please SelectNoYesProvide name and date(s) of each lecture or presentation*NACCT Main Congress Symposium (Committee and/or Section) Organizer*Assigned Points: 3 pts/symposium | Max Points: 9Please SelectNoYesProvide name and date(s) of each symposium*NACCT Main Congress Symposium (Committee and/or Section) Speaker (Does not Include Platform Sessions or Lightening Orals)*Assigned Points: 2 pts/symposium | Max Points: 6Please SelectNoYesProvide Name and Date(s) of each lecture or presentation*NACCT Main Congress Symposium or AACT Pre-Symposium Moderator*Assigned Points: 1 pts/symposium | Max Points: 4Please SelectNoYesProvide Name and Date(s) of each symposium/pre-symposium moderated*NACCT Abstract Committee Chair/Co-Chair*Assigned Points: 4 pts/year | Max Points: 8Please SelectNoYesProvide Years of Service*NACCT Abstract Reviewer*Assigned Points: 1 pt/year | Max Points: 4Please SelectNoYesProvide Years of Service*NACCT Poster, Platform, and/or Lightening Oral Presenter*Assigned Points: 1 pt/year | Max Points: 4Please SelectNoYesYear(s) and Abstract Title(s)* Section 2: Other Sustained Contributions to Toxicology Fellows of AACT are expected to contribute to the field of toxicology beyond AACT and NACCT. Section 2 captures sister society contributions and other toxicology related activities. Section 2. Other Sustained Contributions to Toxicology is is separated into two subsections: 2.1.: Sister Society /Medical Society Contributions/Activities 2.2: Other Sustained Toxicology Related Contributions/Activities - Toxicology Related Education/Teaching- Toxicology Journals/Publications- Toxicology Related Service2.1.: Sister Society /Medical Society Contributions/ActivitiesHave you served as a Sister Society Committee or Section Chair? (i.e. ACMT Fellowship Director Committee Chair)*Assigned Points: 2 pts/year | Max Points: 6Please SelectNoYesName of Sister Society Committee/Section and Dates of Service*Have you served as a Sister Society Committee or Section Member? (i.e. ACMT Fellowship Director Committee Member)*Assigned Points: 1 pts/year | Max Points: 6Please SelectNoYesName of Sister Society Committee/Section and Dates of Service*Sister Society Symposium Organizer/Chair (i.e. NACCT ACMT Pre-Symposium, ASM Symposium Organizer)*Assigned Points: 3 pts/symposium | Max Points: 9Please SelectNoYesName the meeting, date and title of each symposium*Sister Society Symposium Speaker (i.e. NACCT ACMT Pre-Symposium, ASM Symposium Organizer)*Assigned Points: 2 pts/symposium | Max Points: 6Please SelectNoYesName the meeting, date and title of each presentation*Toxicology Specific Abstract or Platform Presenter (Non-NACCT meetings)*Assigned Points: 0.5 pt/presentation | Max Points: 4Please SelectNoYesYear(s) and Abstract Title(s)*Grant Recipient for Toxicology-Related Work*Assigned Points: 1 pt/grant | Max Points: 4Please SelectNoYesList the years, titles and funders of your clinical toxicology grants you have recevied*Toxicology Related Medical Society Service (i.e. ACEP Toxicology Section Chair)*Assigned Points: 0.5 pts/year | Max Points: 4Please SelectNoYesName of Medical Society Service, Description and Dates* Section 2.2 : Other Sustained Toxicology Related Contributions/ActivitiesToxicology Related Education/TeachingCompletion of Clinical/Medical Toxicology Fellowship?*Assigned Points: 1 pt | Max Points: 1Please SelectNoYesWhere and when did you complete your clinical/medical toxicolgy fellowship?*Academic Appointment*Assigned Points: 2 pts = Professor | 1 pt = AssociatePlease SelectNoYes - ProfessorYes - AssociateWhere is your academic appointment?*Toxicology Fellowship Director?*Assigned Points: 1 pt | Max Points: 1Please SelectNoYesLocation and dates of your toxicology fellowship directorship*Toxicology Fellowship Faculty?*Assigned Points: 0.5 pts | Max Points: 0.5Please SelectNoYesLocation, Dates, and Brief Description of Teaching Responsibilities (students, residents, fellows)*Evidence of Sustained Teaching Students, Residents, and/or Fellows (i.e. Preceptorship)*Assigned Points: 0.5 pts | Max Points: 0.5Please SelectNoYesLocation and Brief Description of Sustained Teaching to Students, Residents, and/or Fellows*Didactic Toxicology Lecturer?*Assigned Points: 0.5 pts | Max Points: 0.5Please SelectNoYesLocation, Dates, and Brief Description of Didactic Toxicology Lecturing*Toxicology Related Teaching Awards?*Please SelectNoYesAssigned Points: 1 pt/award | Max Points: 4List all awards, issuer and the years received* Toxicology Journals/PublicationsToxicology Related Journal Editor (non-ClinTox Journal)*Assigned Points: 0.5 pts/year | Max Points: 2 ptsPlease SelectNoYesList the name of the journal and years of service as editor.*Toxicology Related Journal Editorial Board (non-ClinTox Journal)*Assigned Points: 0.5 pts/year | Max Points: 2 ptsPlease SelectNoYesList the name of the journal and years of service on the editorial board.*Toxicology Related Journal Reviewer (non-ClinTox Journal)*Assigned Points: 0.5 pts/year | Max Points: 2 ptsPlease SelectNoYesList the Journal, Years of Service and Average Number of Reviews per Year.*Peer Reviewed Publications related to Toxicology (non-ClinTox Journal)*Assigned Points: 1 pt/publication | Max Points: 4 ptsPlease SelectNoYesList the Journal, Dates, and Titles of Your Publications*Toxicology Textbook Editor?*Assigned Points: 2 pts/textbook | Max Points: 4 ptsPlease SelectNoYesList the years of service and the titles of the textbooks you served as an editor for*Authors of Textbook Chapters related to Toxicology?*Assigned Points: 1 pt/chapter | Max Points: 4 ptsPlease SelectNoYesList the Textbook and the Chapter #/Title for each Chapter Authored/Co-Authored* Toxicology Related ServicePoison Center Director or Medical Director?*Assigned Points: 1 pt | Max Points: 1 ptPlease SelectNoYesPoison Center Name, Role, and Years of Service*Consultant to a Poison Center?*Assigned Points: 0.5 pts | Max Points: 0.5 ptsPlease SelectNoYesList the Poison Center and Years of Service as a Consultant for*Active Practice of Toxicology for 5+ Years? Toxicology focused career (e.g., bedside consults, advocacy, poison center, teaching, research)*Assigned Points: 0.5 pts | Max Points: 0.5 ptsPlease SelectNoYesPlease Describe*Toxicology focused Legal, Government, or Community Activities? (e.g., community meetings, advocacy, expert witness, legislative testimony)*Assigned Points: 0.5 pts | Max Points: 0.5 ptsPlease SelectNoYesPlease Describe* Δ
