ACMQ 2018 Distinguished Fellowship Application

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1. Your current details *This question is required.
Your postgraduate degrees (acronym, e.g., MD) and year earned *This question is required.
Your postgraduate degrees (acronym, e.g., MD) and year earned *This question is required.DegreeYear
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AMA-recognized Specialties
AMA-recognized SpecialtiesSpecialtyBoard Certified (Y/N)Year
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3. Are you currently a Fellow of ACMQ? If yes, in which year did you earn the designation? *This question is required.
  • * This question is required.
4. Attendance at TWO or more ACMQ annual meetings in the last five (5) years: *This question is required.
4. Attendance at TWO or more ACMQ annual meetings in the last five (5) years: *This question is required.YearLocation
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5. CME 120 hours of CME Category I from ACMQ annual meetings, or other educational programs related to quality *This question is required.
5. CME 120 hours of CME Category I from ACMQ annual meetings, or other educational programs related to quality *This question is required.CME activityDatesHours
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6. Are you Certified in Medical Quality (CMQ) by the American Board of Medical Quality? *This question is required.
  • * This question is required.
In the absence of certification in Medical Quality, you must complete at least one (more, if you wish) of the following in order to meet the application requirements.
One year or longer fellowship or training in medical quality management or clinical quality improvement.
One year or longer fellowship or training in medical quality management or clinical quality improvement.InstitutionDates attendedRecognition/designation achieved (if any)
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Upload a statement, on institution letterhead, from your program/fellowship director confirming your training and/or fellowship.
[Upload only MS-Word or pdf files of up to 1MB]
OR One year or longer employment in medical quality management or clinical quality improvement.
OR One year or longer employment in medical quality management or clinical quality improvement.EmployerEmployment datesJob title
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OR Authorship of a book or book chapter, on a topic related to quality, accepted and published.
OR Authorship of a book or book chapter, on a topic related to quality, accepted and published.Name of book and/or book chapter publishedCitation and date of publication
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OR Authorship of TWO articles, on topics related to quality, accepted by and published in the American Journal of Medical Quality, or other peer-reviewed journal. In the Comments box, enter the journal/publication names, citations, and dates of publication.
[Upload only MS-Word or pdf files of up to 1MB]