Special Purpose Examination (SPEX GENERAL APPLICATION INSTRUCTIONS

Transcription

Special Purpose Examination (SPEX GENERAL APPLICATION INSTRUCTIONS
Special Purpose Examination (SPEX®)
GENERAL APPLICATION INSTRUCTIONS
ELIGIBILITY
SPEX is designed for physicians who hold or have held a valid, unrestricted medical license in a United States
or Canadian jurisdiction. To be eligible for the SPEX you must meet all eligibility requirements established by
the Federation of State Medical Boards (FSMB) and the state medical board for which the SPEX is being taken.
APPLICATION MATERIALS
Your application materials should include the SPEX Application, SPEX Information Bulletin, and these
General Application Instructions. Be sure to read the SPEX Information Bulletin carefully before completing
the application.
COMPLETING THE APPLICATION
Part A: Complete Part A in its entirety, following the instructions provided for each item on the application.
Code lists are included with the instructions.
Part B: To be completed by the Medical Licensing Authority for which SPEX is being taken.
Identification page: One 2” x 2” passport type photo is required. Print your full name on the back of the photo
attach to the identification page. Complete the requested information, including your signature under the photo.
The identification page must be notarized, and the notary seal or stamp must fall partly on the photo and partly
on the signature under the photo.
A photocopy of your medical license is required for Board Sponsored and Self-Nominated applications.
TESTING ACCOMMODATIONS
Reasonable accommodations are provided to examinees with documented disabilities as defined by the
Americans with Disabilities Act as amended in 2008, together (“ADA”). If you are a disabled individual
covered under the ADA and require test accommodations, contact the FSMB for information regarding
procedures and documentation requirements.
This information is also available from the website at www.fsmb.org. In all cases, requests for testing
accommodations must be made in writing at the time the SPEX application is submitted.
PAYMENT INSTRUCTIONS
The fee for SPEX is $1300, payable by check or money order to the FSMB. Payment must be submitted with
the application. $650 of the SPEX application fee is nonrefundable.
APPLICATION MAILING INSTRUCTIONS
Mail your completed application and payment to the Medical Licensing Authority for which SPEX is being
taken.
PROCESSING THE APPLICATION
Applications are processed by date of receipt at the FSMB offices. Allow approximately one to three weeks for
processing once the FSMB receives your application from the medical licensing authority. You are advised to
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SPEX Basic Service Gen Inst 11/2014
consult the board for their current application processing time and add this to the FSMB’s two-to-four week
processing time.
SCHEDULING THE EXAMINATION
You will receive a Scheduling Permit with detailed information on how to schedule the exam at a Prometric
Testing Center. SPEX is available across the nation throughout the year. You will have approximately 90days in
which to schedule and complete the SPEX. You must present your permit and an unexpired government issued
form of identification with your photograph and signature (such as a driver’s license or passport) to be admitted
to the testing center.
ELIGIBILITY EXTENSION
If you need to extend your eligibility period, you may submit an eligibility extension request for review. If your
request is approved, a one-time contiguous 90-day extension may be granted. To request an extension, you must
complete the Eligibility Extension request form and submit with a $65 processing fee.
SCORES
Scores will be released approximately two to four weeks after the exam has been taken.
ADDRESS CHANGES
Correspondence regarding your application, scheduling information, and scores will be directed to the address
provided on your application. Therefore, it is essential that a correct address be provided and that appropriate
changes are submitted in writing to:
Attn: Assessment Services
Federation of State Medical Boards
400 Fuller Wiser Road, Suite 300
Euless, TX 76039-3856
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SPEX Basic Service Gen Inst 11/2014
Board Codes (Alphabetical)
001 Alabama
002 Alaska
056 American
Samoa
003 Arizona
903 Arizona Osteo
004 Arkansas
005 California
905 California Osteo
006 Colorado
007 Connecticut
008 Delaware
009 District of
Columbia
010 Florida
910 Florida Osteo
011 Georgia
055 Guam
012 Hawaii
013 Idaho
014 Illinois
015 Indiana
016 Iowa
017 Kansas
018 Kentucky
019 Louisiana
020 Maine
021 Maryland
022 Massachusetts
023 Michigan
024 Minnesota
025 Mississippi
026 Missouri
027 Montana
028 Nebraska
029 Nevada
030 New Hampshire
031 New Jersey
032 New Mexico
033 New York
034 North Carolina
035 North Dakota
086 Northern Mariana
Islands
036 Ohio
037 Oklahoma
038 Oregon
039 Pennsylvania
053 Puerto Rico
040 Rhode Island
041 South Carolina
042 South Dakota
043 Tennessee
044 Texas
045 Utah
046 Vermont
054 Virgin Islands,
United States
047 Virginia
048 Washington
948 Washington Osteo
049 West Virginia
050 Wisconsin
051 Wyoming
Country Codes (Alphabetical)
118
120
125
056
127
128
103
129
130
132
138
107
143
154
156
111
157
155
113
160
162
164
090
165
166
170
171
173
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Azores
Bahamas
Bahrain
Balearic Islands
Bangladesh
Barbados
Belarus
Belau
Belgium
Belize
Benin
Bermuda
Bhutan
176
668
178
180
187
115
970
116
945
191
198
207
211
215
217
098
114
219
104
225
228
101
231
243
108
109
Bolivia
Bonaire
Bosnia-Herzegovina
Botswana
Brazil
British Antarctic
Territory
British East Africa
British Indian
Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Canary Islands
Cape Verde
Cayman Islands
Central African
Republic
Chad
Channel Islands
Chile
China
Christmas Island
Cocos Islands
3
264
265
727
117
100
270
273
275
667
968
280
281
966
286
297
300
305
308
980
410
319
915
341
946
355
345
360
366
Colombia
Comoros
Congo
Cook Islands
Corsica
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Cyprus (Greek)
Cyprus (Turkish)
Czech Republic
Czechoslovakia
Denmark
Djibouti
Dominica
Dominican Republic
Dutch East Indies
East Germany
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Estonia
Ethiopia
367
140
368
374
396
398
399
145
397
402
406
409
412
414
418
420
422
427
055
429
435
436
438
440
451
462
473
484
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern /
Antarctic Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
SPEX Basic Service Gen Inst 11/2014
495
506
517
528
539
102
550
561
563
566
572
575
576
577
580
969
India
Indonesia
Iran
Iraq
Ireland
Isle Of Man
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
649
082
084
650
651
652
653
654
655
657
209
658
659
672
660
665
Mexico
Micronesia
Midway Islands
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
773
781
148
785
790
573
662
792
581
584
587
590
595
605
607
610
613
615
616
618
619
621
620
112
622
624
623
625
627
086
080
630
632
634
141
669
Kosovo
Kuwait
Kyrgyz Republic
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Madeira Islands
Malawi
Malaysia
Maldives
Mali
Malta
Mariana Islands
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Media
144
671
682
688
690
147
110
582
152
952
949
693
695
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
North Vietnam
North Yemen
Northern Ireland
Norway
Oman
Pacific Islands
Trust Territory
Pakistan
Palestinian Authority
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Portuguese Timor
Puerto Rico
Qatar
794
088
704
560
715
720
726
737
748
105
759
770
771
053
772
4
793
661
306
666
395
142
798
796
797
947
820
821
822
823
496
825
663
967
826
828
830
836
150
583
151
153
953
847
220
000
848
850
Reunion
Romania
Ross Dependency
Russia
Rwanda
Ryukyu Islands
Saba
Saint Barthelemy
Saint Helena &
Dependencies
Saint Kitts & Nevis
Saint Lucia
Saint Maarten
Saint Martin
Saint Pierre &
Miquelon
Saint Vincent And
The Grenadines
San Marino
Sao Tome & Principe
Saudi Arabia
Scotland
Senegal
Serbia
Seychelles
Sierra Leone
Sikkim
Singapore
Sint Eustatius
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sandwich
Islands
South Vietnam
South Yemen
Spain
Sri Lanka
Stateless
Sudan
Suriname
855
858
869
875
244
882
880
891
893
149
892
894
895
902
903
106
904
905
908
916
917
999
924
099
913
928
930
932
935
941
054
092
948
146
411
158
795
951
957
266
965
775
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos
Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Unknown
Uruguay
USA
USSR
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands
Wake Island
Wales
Wallis And Futuna
West Germany
Western Sahara
Western Samoa
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
SPEX Basic Service Gen Inst 11/2014
Allopathic (M.D.) Specialty Code List (Alphabetical)
01 Allergy & Immunology
02 Anesthesiology
03 Colon & Rectal Surgery
04 Dermatology
05 Emergency Medicine
06 Family Practice
07 Internal Medicine
42 Medical Genetics
08 Neurological Surgery
09 Neurology
10 Nuclear Medicine
11 Obstetrics & Gynecology
12 Ophthalmology
13 Orthopedic Surgery
14 Otolaryngology
21 Radiology
15 Pathology
22 Surgery
16 Pediatrics
23 Thoracic Surgery
17 Physical Medicine & Rehabilitatio2n4 Urology
18 Plastic Surgery
19 Preventative Medicine
20 Psychiatry
Osteopathic (D.O.) Specialty Code List (Alphabetical)
43 Allergy & Immunology
25 Anesthesiology
26 Dermatology
27 Emergency Medicine
44 Family Medicine
28 General Practice
29 Internal Medicine
30 Neurology & Psychiatry
31 Nuclear Medicine
32 Obstetrics & Gynecology
5
33 Ophthalmology &
Otorhinolaryngology
34 Orthopedic Surgery
35 Pathology
36 Pediatrics
37 Preventative Medicine
38 Proctology
39 Radiology
40 Rehabilitation Medicine
41 Surgery
SPEX Basic Service Gen Inst 11/2014
Special Purpose EXamination (SPEX)®
Application for SPEX
Part A. - To be completed by applicant.
Refer to the Application Instructions when completing this form. Complete all pages and print in ink or type.
1. Name
Print your name exactly as it
appears on the unexpired,
government-issued identification
you plan to present at the test
center.
Last (Surname) and suffix
First and Middle names
If you have applied previously under another name for any examination listed in section 7 of this form, please provide
that name.
Reason for Change:
If you have not notified us previously of your name change and want your name changed on the official SPEX record,
you must provide a copy of legal documentation that verifies this change.
2. Date of Bir th
Abbreviate months as: JAN,
FEB, MAR, APR, MAY, JUN,
JUL, AUG, SEP, OCT, NOV,
DEC.
3. U.S. Social Securi ty
and Nati onal
Ide nt ifi ca ti on N umber s
Enter your SS number
and/or the official number
assigned by your country if
outside the U.S. See
instructions for country
codes.
Month
Day
Year
U.S. Social Security Number
National Identification Number
4. Gender
Male
5. Citizenship upon
entering Medical School
See instructions for country
codes.
Country Code
Country Code
Name of Country
Female
Name of Country
Medical School of Graduation
6. Medical Educati on
See instructions for country
codes. G radu at i on Date:
Abbreviate months as: JAN,
FEB, MAR, APR, MAY, JUN,
JUL, AUG, SEP, OCT, NOV,
DEC.
Country Code
Graduation Date
Month
Degree:
7. Examination History and
Ide nt ifi ca ti on N umber
Indicate all the examinations
that you have taken.
Country of Medical School
M.D.
Year
D.O.
Other (specify)
Exam ination
Identification Number (if known)
FLEX
FLEX
USMLE Step 1, Step 2, or Step 3
USMLE
NBME Part I, Part II, or Part III
NBME
ECFMG FMGEMS/NBME Part I or Part II/VQE
ECFMG
SPEX
SPEX
Specialty of current practice
8. Speci al ty
See instructions for specialty
codes.
Are you certified in this specialty by an ABMS or AOA-BOS -approved board?
Yes
No
Are you certified in another specialty by an ABMS or AOA-BOS -approved board?
Yes
No
If yes, give code(s) of other specialty(ies)
Page 1
a.
b.
c.
9. Li cens e (s ) hel d
See instructions for state board
codes. You must provide a
photocopy of your medical
license.
License Number
Board Code
License Number
Board Code
License Number
Board Code
10. Addr ess
This address will be used for
correspondence regarding
registration for SPEX. Print
your current mailing address.
Address Line 1
If you provide an address
outside the U.S.,
correspondence relating to
SPEX may be significantly
delayed. Provide a U.S.
address, if possible.
Address Line 3
If your address changes or is
different for score reporting, see
Instructions, “Address
Changes.” See Instructions
for Country Code.
Address Line 2
City
State/Province
Country
Country Code
Code
ZIP/Postal
(
)
Daytime Telephone Number
11. Test Accommodati ons
12. S i gnat u re Review the
SPEX Information Bulletin
before signing this
statement.
E-mail address
I have a documented disability covered under the American with Disabilities Act and am requesting test accommodations.
(Checking this box does not constitute an official request. You must submit your request for test accommodations
and accompanying documentation at the same time as this application. See Instructions, “Testing
Accommodations.”)
I certify that I currently meet the SPEX eligibility requirements, that the information provided on this form is true and accurate. I
also certify that I have read the current SPEX Information Bulletin and the application instructions, that I am familiar with their
contents, and agree to abide by the policies and procedures described therein. I understand that I may be required to verify my
eligibility for this examination, and I agree to pay any related fees.
Applicant Signature
Date
Provision of the following information is voluntary. The information will be used for research purposes only. You are encouraged to provide the information.The
processing of your application will not be affected by your choice in this regard.
Select the option which best
describes your race/ethnicity
Is English your native language?
1
2
American Indian/
Alaskan Native
3
Asian
Yes
5
4
Native Hawaiian or
other Pacific Islander
Hispanic or
Latino
Black or African
American
6
White
No
Part B. — To be completed by Medical Licensing Authority
1. Lice ns in g Au th or ity for
which SPEX is being taken.
2. State Board Contact
3. Licensure Histor y
4. Examinee’s Purpose for
taking SPEX.
Page 2
Name of Licensing Authority
Board Code
Name of contact
Title
Signature
Date
Does applicant currently hold an unrestricted license
in any U.S. jurisdiction?
License by endorsement
Yes
License number
No
Board Code
Required as part of a disciplinary process
License number
Board Code
Reactivation of an inactive license
License number
Board Code
7
Other
Securely affix in this square a
current front-view, 2” x 2”
photograph of head and shoulders,
which should approximately fill the
space. (Print full name on back of
photograph before attaching.)
Special Purpose Examination
Identification Card
Name
(Please print or type) Last
Date of Birth: _______
Month
First
Day
Gender:
Year
Middle Initial
Male
Female
Certification of Identification
Certification by Notary Public or Commissioner of Oaths is required.
SEAL
The impression of the seal must be
partly upon the photograph and
partly upon the signature of the
applicant
Applicant Signature
By my signature above, I certify that all
of the information provided on this form
is true and accurate.
Page 3
State of
County of
I certify that on the date set forth below, the individual named above did appear personally before
me and that I did identify this applicant by: (a) comparing his/her physical appearance with the
photograph on the identifying document presented by the applicant with the photograph affixed
hereto and (b) comparing the applicant’s signature made in my presence on this form with the
signature on his/her identifying document. The statements in this document are subscribed and
sworn to before me by the applicant on this
day of
,
.
Day
Notary Public Signature
Month
Year