Fellow Application

2016
ACOFP FELLOW
AWARD APPLICATION
QUALIFICATIONS & REQUIREMENTS
The designation, Fellow of the American College of Osteopathic Family Physicians (FACOFP), signifies the recognition
of the member’s experience, dedication, and contributions of the highest order to the advancement of family
practice by his/her peers.
QUALIFICATIONS
The Award of Fellow in the American College of Osteopathic Family Physicians may be conferred on founder
and active members who have:
Contributed outstandingly through teaching, authorship, research, professional leadership, or as a moderator
at ACOFP CME convention lectures.
Has been an active dues-paying member at any level of the ACOFP for at least six consecutive years prior to
nomination.
Served a one-year AOA-approved internship, or its equivalent. In the event the nominee has not served a
one-year AOA-approved internship or its equivalent, the nominee shall have been an active dues-paying
member of this College for at least eight consecutive years prior to nomination.
Be certified by the American Osteopathic Association (AOA) or the American Board of Medical
Specialists (ABMS).
Actively participate in local and state osteopathic organizations and ACOFP affiliate societies.
Supported past and current hospital, state society, and national activities of the ACOFP.
Nominees must have attended and registered as a family physician a minimum of at least six ACOFP or
AOA/ACOFP Annual Conventions in the immediate past ten years.
At least three meetings must be ACOFP Annual Conventions and the remainder may be OMED Annual
Conventions. One ACOFP Annual Convention meeting during residency may be used for one of the three
ACOFP Annual Convention meeting requirements. One ACOFP Intensive Update & Board Review in
Osteopathic Family Medicine may be used in place of an OMED Annual Convention.
Candidate may count the ACOFP Annual Convention they become a Fellow as one of the ACOFP Conventions
attended.
A nominee in the military who is unable to attend the ACOFP and OMED Annual Conventions may substitute
up to three AMOPS (Association of Military Osteopathic Physicians & Surgeons) Conventions for AOA Annual
Conventions. The AMOPS meeting substitution applies only to those on “active duty.”
Completed applications are due to ACOFP by September 15, 2015 for the next Fellows Award Ceremony,
taking place April 2016 in San Juan, Puerto Rico.
ACOFP FELLOW | AWARD APPLICATION
REQUIREMENTS
Please notify ACOFP with the name of the sponsor and nominee prior to submission of application paperwork
at [email protected].
Each Fellow application must be accompanied by a letter of endorsement by the sponsor and a letter of
recommendation from the ACOFP state society, if applicable. If there is no state society, a letter from another
ACOFP Fellow who practices in the area or state of the nominee is acceptable.
The application must include the completion of an unpublished scientific paper pertinent to family medicine
and suitable for publication. The candidate must attest that he/she is the primary author of the submitted,
unpublished scientific paper. This paper will be submitted to the sponsor one month in advance for initial
review, editing and approval. The sponsor must submit a written appraisal of the nominee’s paper, which
must be included in the nominee’s file prior to consideration. All scientific papers that are
submitted shall become the property of ACOFP.
To receive consideration of a Crest Award or Outstanding Paper Award please follow the suggested guidelines
for scientific papers: Text should be limited to 3,000 words. This should include a 250-word abstract,
footnotes and references. If charts or pictures are referenced or copied from other sources, permission
should be sought from the author in advance.
A fee of $195 must be submitted by the sponsor of the nominee and shall accompany the Fellow nomination
to cover administrative and Awards Committee expenses. A suitable portion of the fee ($195 or less), as
determined by the ACOFP Board of Governors, shall be refunded to the sponsor of an unsuccessful
candidate.
Upon notice of approval by the Awards Committee and ACOFP Board of Governors, the successful nominee
shall pay an additional $375 to cover administrative fees, nominee cap and gown rental, ceremony expenses
and the Fellow presentation plaque. This amount will be due prior to the nominee receiving his/her award.
The plaque will become the property of the nominee.
Fellow Applications shall be sent to Fellow sponsors and Fellow application requests.
Any active Fellow may nominate only one qualified member for the Award of Fellow each year.
This Award shall not be conferred on any person outside of the osteopathic profession.
Notwithstanding any of the requirements herein above stated, the ACOFP Board of Governors shall have the
authority, in its discretion, to confer the Award of Fellow in the ACOFP on an Active Member, in addition to
those nominated by the Awards Committee. The nominee shall be approved by majority of the ACOFP Board
of Governors. Nominations shall be made as confidential as possible.
Should the Awards Committee find that a candidate does not meet the requirements, the sponsor will be
contacted for consultation.
All completed applications must be postmarked no later than September 15, 2015 for the next Fellows Award
Ceremony, taking place April 2016 in San Juan, Puerto Rico.
ACOFP FELLOW | AWARD APPLICATION
APPLICATION CHECKLIST
This checklist must be completed by the nominee and submitted before September 15, 2015 with documentation
supporting the categories below.
SPONSOR
Enclose check for $195. MUST be submitted by the Sponsor.
Completed application.
Incomplete applications will not be accepted. Please do not write “refer to CV.”
Letter of recommendation.
Edited paper and completed Scientific Paper Appraisal Report Form.
NOMINEE
AOA#:
Must be an ACOFP Active Member for six consecutive years.
Letter of recommendation by ACOFP State Society, if applicable, or a letter from another ACOFP Fellow who
practiced in the area or state of the nominee must be enclosed.
Include a color photo (publication quality). Digital photos preferred. Send to ACOFP via email at
[email protected].
Completed annual ACOFP and AOA Convention attendance form - must enclose AOA printout.
Current Curriculum Vitae enclosed (CV should include public/community service).
An original, primary author and unpublished paper enclosed. Send an electronic copy of paper to ACOFP via
email at [email protected].
Refer to the Fellows “How to Write a Scientific Article” and “Suggestions for Article Types in Osteopathic Family
Physician” to review all the steps required of a Fellow Nominee preparing a scientific paper, beginning with the rough
draft manuscript to the published paper.
ACOFP FELLOW | AWARD APPLICATION
APPLICATION
Please complete and submit before September 15, 2015.
Certified by AOA?
Name of Nominee:
YES
Name of Sponsor:
Phone:
Cell Phone:
Office Phone:
Fax:
Email:
Office Address:
City:
State:
Zip:
State:
Zip:
Home Address:
City:
Nominee Signature
Date
Sponsor Signature
Date
Completed applications are due to ACOFP by September 15, 2015 for the next Fellows Award Ceremony,
taking place April 2016 in San Juan, Puerto Rico.
American College of Osteopathic Family Physicians
Awards Committee
330 E. Algonquin Road, Suite 1
Arlington Heights, IL 60005
For questions call 800.323.0794 or email [email protected]
NO
ACOFP FELLOW | AWARD APPLICATION
EDUCATION
Pre-Professional College(s) Attended (Give degree earned):
Name of School
City
STATE
YEARS ATTENDED
DEGREE
City
STATE
YEARS ATTENDED
DEGREE
Professional College Attended:
Name of School
HONORARY DEGREES:
List years and locations of general osteopathic medicine:
List memberships in local, state, or national family medicine organizations and years:
Nominee Signature:
Date:
ACOFP FELLOW | AWARD APPLICATION
OFFICES & MEMBERSHIPS HELD
List past offices held in these organizations:
List current hospital affiliations:
List current state osteopathic licenses held:
List local, state, and national professional memberships:
List offices held in all professional organizations and years:
Use additional pages for Civic activities, offices held, and honors received.
Enlarge on all credits held.
Nominee Signature:
Date:
ACOFP FELLOW | AWARD APPLICATION
CONVENTION ATTENDANCE
List the last six ACOFP or AOA Annual Conventions attended and registered as a family physician in the past ten
years. Indicate attended conventions on AOA CME report.
• At least three MUST be the spring ACOFP Annual Convention
• The remaining three may be fall OMED Annual Convention
• One ACOFP Intensive Update may count as an OMED Annual Convention
• May count the convention they become a Fellow as one of the ACOFP Conventions attended.
CONVENTION
1.
2.
3.
4.
5.
6.
YEAR
ACOFP FELLOW | AWARD APPLICATION
SCIENTIFIC PAPER APPRAISAL REPORT
Name of Nominee:
AOA#:
Name of Sponsor:
Scientific Paper Title:
As Sponsor of the above Nominee, I have read the attached scientific paper and feel that the paper is:
Excellent
Good
Satisfactory
Not very good
Poor
COMMENTS:
Sponsor Signature:
Date: