Recertification Form



The Academy of Toxicological Sciences

ATS Recertification

GENERAL INSTRUCTIONS

To renew your certification, please download this form, create a file named: Your Last Name - ATS Recertification.doc, complete the form as instructed, and send electronically to ATS Headquarters to the attention of Susie Masten, smasten@. Note that applications with “See Attached CV” will be returned without review. No attachments will be considered.

The intent of recertification is to document your continuing active practice and recognition in the profession of toxicology. Responses should be restricted to activities in the PAST 5 YEARS ONLY.

NOTE: All applications will be reviewed for the following:

• Evidence of continued education and training

A general statement that a Fellow has attended formal CE courses (a) or stand-alone courses, workshops, or webinars (b) is not acceptable. There should be a listing of the events.

• Evidence of professional contribution and accomplishments in toxicology

• Evidence of the applicant’s continuing practice in toxicology.

Please note that your request for recertification will not be reviewed by the Board until the recertification fee of $150 has been received by ATS Headquarters. See the following link to provide online payment: or send a check to ATS, PO Box 98954, Raleigh, NC 27624.

RECERTIFICATION APPLICATIONS ARE DUE ON JUNE 30.

The Academy of Toxicological Sciences

ATS Recertification Form

|Date | |

|Full Name | |

|Mailing Address | |

| | |

|Business Phone | |

|Home Phone | |

|Fax | |

|Email | |

SECTION 1: DEGREES AND CERTIFICATIONS

Education Beyond Terminal Degree

If you have advanced your toxicology-relevant education beyond the terminal degree at the time of initial certification or your most recent recertification, please provide the information below. If none, please mark “No Change”.

______ No Change

|Degree |Institution |Year Received |

| | | |

| | | |

| | | |

Additional Toxicology-Related Certifications

If you have become certified (or re-certified) by other toxicology-related organizations since the time of initial ATS certification or your most recent ATS recertification, please provide the information below. If none, please mark “No Change”.

______ No Change

|Certification |Certifying Organization |Year Received |

| | | |

| | | |

| | | |

SECTION 2: CONTINUOUS PROFESSIONAL DEVELOPMENT

Continuing Education

This section is intended to capture your efforts on continuing education and professional development in the field of toxicology over the past 5 years. Information is broken down into formal CE courses (such as those often offered by societies at their annual meeting), stand-alone workshops and symposia (e.g., courses offered by societies separate from their annual meeting, courses offered by Societies outside of their annual meetings such as Contemporary Concepts in Toxicology (CCT) symposia offered by the SOT, PERI courses, etc.), and webinars indicative of professional development. Notes: 1) You may include courses in which you were the chair/co-chair, course developer, or an invited speaker; however, your role as invited speaker or chair/co-chair should be addressed separately in Section X below. 2) Professional meeting attendance will be captured later in Section Y.

a. In the box below, provide a list of formal CE training including course title, location, and date (MM/YY) and approximate number of hours for each course:

| |

| |

b. In the box below, provide a list of stand-alone courses, workshops, or webinars attended including title/topic, sponsoring organization, and date (MM/YY). Do not include courses, workshops, or symposia which are part of the Annual Meeting of a scientific society.

| |

| |

c. In the box below, provide a list of professional society meetings attended (no need to list individual session attendance) and date (MM/YY):

| |

| |

Publications

This section is intended to capture your toxicology-relevant publications within the last 5 years ONLY. This includes original research articles, review articles, books edited, book chapters, etc. If your external publication record is limited by employment circumstances, you should provide a listing of employment-related scholarly analyses indicative of practice of toxicology (e.g., preparation of regulatory dossiers for FIM or registration, protocols and toxicity test reports, etc.) Note that proprietary details are not required; describe the number and general nature of the analyses. If your job function is to review/edit reports and dossiers for regulatory submissions, this should be captured under the section Editorial Boards and Other Editorial Responsibilities below.

a. In the box below, provide a listing of peer-reviewed research publications from the past 5 years (highlight your name in the list of authors):

| |

| |

b. In the box below, provide a listing of review articles from the past 5 years:

| |

| |

c. In the box below, provide a listing of books and book chapters from the past 5 years:

| |

| |

d. In the box below, provide a listing of employment-related scholarly analyses indicative of the active practice of toxicology as described in the header above such as authoring sections of regulatory dossiers (list agent) and technical reports:

| |

| |

Presentations

This section is intended to capture your toxicology-relevant presentations (posters, platform, session speakers, oral and platform presentations of toxicology-related research at national and international meetings, integrated analyses, educational lectures, etc., within the past 5 years ONLY. Include abstracts, poster sessions or INVITED oral and platform presentations at symposiums or workshops, seminars, lectures, etc., as well as other professional society meetings.

a. In the box below, provide a list of INVITED presentations including the event/session and date (MM/YY). This includes invited educational lectures. Note: This is where your invited speaker listings from the Continuing Education section above should be provided.

| |

| |

b. In the box below, provide a listing of abstracts (oral and poster) presented including authors, title, location, and date (MM/YY):

| |

| |

Editorial Boards and Other Editorial Responsibilities

This section is intended to capture your toxicology-relevant editorial responsibilities both for peer-reviewed journals as well as editorial responsibilities you may have as part of your job responsibilities within the past 5 years ONLY.

a. In the box below, provide a list of all journals for which you are on the official Editorial Board, Associate Editor, or Editor. Include journal name, role, and dates (YY-YY). DO NOT include journals for which you serve as an ad hoc reviewer.

| |

| |

b. If your job responsibilities require you to provide editorial support for technical reports, regulatory dossiers, etc., please provide a listing of those here. For regulatory dossiers, only include FIM-enabling, CTD (e.g., 2.4, 2.6.6). Do not include technical reports of dossiers for which you are the original authors. Those are captured in the Publications section above. Do not include all responses to regulatory queries. For technical reports, please include the number of reports in the past 5 years, the type (e.g., chronic repeat dose toxicity, safety pharmacology, investigative, etc.).

| |

| |

Society Memberships and Professional Service in Toxicology

This section is intended to capture your continued active participation in and service to toxicology-relevant societies over the past 5 years ONLY, and/or other professional engagements with toxicology-related industry, government, academic, and/or non-governmental organizations. This includes service on professional society committees, service on internal (job-related) or external advisory or decision-making panels (including training of students/postdoctoral fellows), etc. DO NOT list activities already described in other sections of this application (may be referenced).

a. In the box below, provide a list of your toxicology-related society memberships.

| |

| |

b. In the box below, provide a list of your service to toxicology and related professional societies including the society, activity/committee, and dates (YY-YY).

| |

| |

c. In the box below, provide a list of your service to industry, government (e.g., including national and international decision-making panels), academic, and/or non-governmental organizations including the organization, activity/committee, and dates (YY-YY).

| |

| |

d. In the box below, provide a list of events that you have organized that have been presented (e.g., annual meeting session Chair/Co-Chair, etc.) including the type of activity (e.g., workshop, symposium, CE course, etc.), title of the activity, where presented, and date (YY). Do not include poster session chairpersonships.

| |

| |

e. In the box below, provide a list of students/postdoctoral trainees or industry interns for which you have been the primary advisor or committee member in the past 5 years including trainee/intern name, institution, your role, and date (YY-YY).

| |

| |

SECTION 3: CAREER DEVELOPMENT AND HONORS/AWARDS

Professional Career Advancement

In the box below, please list your current employer and job function. Provide a listing of employment-related advancement in positions, or growth of responsibilities within the positions held in the last 5 years.

| |

| |

Honors and Awards

Please list any awards received in toxicology or related fields, professional society recognition, employer awards, grants, press release on research, etc.

|Organization |Award Name |Year Received |

| | | |

| | | |

| | | |

| | | |

SECTION 4: OTHER RELEVANT INFORMATION

Other Information

This section is optional and may be left blank. In the box below, please include any additional information not captured above that is relevant to demonstrating your continuing active practice and recognition in the profession of toxicology. This space may also be used to provide the Board additional commentary regarding your recertification.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download