Application form for Fellow of the AACT

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

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*

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Service to AACT Core Functions
AACT Board of Trustees Member*
Dates of Term*
AACT Committee Chair*
List name(s) of Committee and Dates of Service*
AACT Committee Member*
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?*
ABAT President*
Dates of Term*
ABAT Board Member*
Dates of Term(s)*
ABAT Committee Chair*
List name(s) of committees and dates of services*
ABAT Committee Member*
Names and dates of Committees and contribution to each*
AACT Section Chair*
Name of Section and dates of service*
AACT Section Member*
Dates of Section Membership and Contribution(s) to each Section*
AACTion Newsletter Editor*
Dates of Service as AACTion Editor*
AACTion Editorial Staff*
Role as Editorial Staff and Dates of Service*
Have you contributed to AACTion?*
List specific topics and dates or type of contribution*
AACT Pre-Meeting Symposium Chair or Organizer at NACCT*
Name and Date(s) of each symposium*
AACT Pre-Meeting Symposium Speaker*
Provide name and date(s) of each lecture or presentation*
AACT Symposium (during NACCT) chair or organizer*
Provide name and date(s) of each symposium*
AACT Symposium (during NACCT) Speaker*
Provide Name and Date(s) of each lecture or presentation*
NACCT Abstract Committee Chair*
List each year served*
NACCT Abstract Reviewer*
List each year served*
Service Contribution to EAPCCT?*
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*
Provide name and date(s) of each lecture or presentation*
Have you served as Editor of Clinical Toxicology*
List dates of service*
Have you served on the Editorial Board for Clinical Toxicology*
List dates of service*
Have you served as a reviewer for Clinical Toxicology*
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.

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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*
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

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Fellow of the AACT Application

Step 1 of 5

Contact Information for Applicant

Service to AACT Core Functions

Service to the Field of Clinical Toxicology

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