Measure Development Technical Expert Panel Application Form

Thank you for nominating yourself or a candidate to the American Psychiatric Association Technical Expert Panel.

As part of completing the form below, please be ready to upload your (or your candidate's) completed conflict of interest form, CV, and letter of support or personal statement.

1. Nomination Checklist *This question is required.

I have read the APA Financial Disclosure Policy and will upload the signed conflict of interest form.
Personal statement or letter of support (if organizational nomination) highlighting experience in quality improvement, leadership, measure development or implementation, and measure concepts (as described on the project web page) etc.
Current CV (10 pages maximum)

2. Please complete the following. *This question is required.

Name (with credentials) *This question is required.

Title *This question is required.

Employer *This question is required.

Medical Specialty *This question is required.

Primary Professional Society Affiliation *This question is required.

3. Preferred Contact Information *This question is required.

Street Address

Apt/Suite/Office

City

State

Zip

Country

Email Address

Phone Number

Mobile Phone

4. If you would like your administrative assistant copied on correspondences, please include their contact information:

First Name

Last Name

Company Name

Email Address

Phone Number

5. Which category best describes your current professional role? (Please select one) *This question is required.

Please enter an 'other' value for this selection.

6. What health care settings are you most familiar with? (Please select ALL that apply) *This question is required.

Please enter an 'other' value for this selection.

7. Clinical Activities

Of the following activities please share whether this is full-time or include a percentage of time allocated to each activity in which you participate. We use this information to construct working groups with appropriate representation.

If you do not participate in a particular activity, please reply "N/A." *This question is required.

Clinical Practice *This question is required.

Clinical Quality Improvement and/or Patient Safety Activities *This question is required.

Medical Education *This question is required.

Research *This question is required.

Administration *This question is required.

Health Plan Representative *This question is required.

Other - Write in (Required)

Other - Write In (Required)

To help us select a diverse membership, we as that you provide the following voluntary demographic information:

8. Race/Ethnicity

Please enter an 'other' value for this selection.

9. If seated to the quality measure technical expert panel, I affirm that I am able to participate in all panel activities and meetings. *This question is required.

Please review the American Psychiatric Association's Financial Disclosure and Conflict of Interest Policy, before uploading your completed conflict of interest form.

Measure Development Technical Expert Panel Application Form

American Psychiatric Association's Measure Development Technical Expert Panel Nomination Form