The American Board of Pediatric Neurological Surgery



The American Board of Pediatric Neurological SurgeryApplication for the ABPNS Written Subspecialty Exam (including submission of a case log) Please read carefully and check (left click and then choose “checked”) the appropriate boxes. Application will not be processed until complete.Part I: Contact and Practice Information Name: Address: Institution: Street: City: State or Province: Zip Code: Country: Phone: Fax: E-mail: Fellowship: Institution: Dates of Training: Director: Date started practice at current Institution: FORMCHECKBOX No restrictions FORMCHECKBOX Restricted If restrictions, explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Part II: Professional Standing Have you received any type of sanction or are you currently FORMCHECKBOX Yes FORMCHECKBOX No under investigation by a hospital, state licensing agency, or other healthcare organization? Have you voluntarily or involuntarily surrendered, retired orrelinquished ANY licensure or registration? FORMCHECKBOX Yes FORMCHECKBOX NoHave you had or do you currently have successful challenges FORMCHECKBOX Yes FORMCHECKBOX No to your DEA or state-controlled substance registration? Have your privileges at ANY hospital or healthcare facility FORMCHECKBOX Yes FORMCHECKBOX Nobeen limited, reduced, suspended, diminished, revoked, or notrenewed by the action of any hospital or healthcare facility? Has your faculty membership at ANY medical center or other FORMCHECKBOX Yes FORMCHECKBOX NoProfessional school been removed or subject to disciplinary action?If you answered YES to any of the questions numbered 1 through 5, please explain in the section immediately below: ____________________________________________________________________________________________________________________________________________________________Licensure Information STATE OR PROVINCE LICENSE NUMBER RESTRICTED OR SUSPENDED_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX No _____________________________________ FORMCHECKBOX Yes FORMCHECKBOX No_____________________ ________________ FORMCHECKBOX Yes FORMCHECKBOX No_____________________ ________________ FORMCHECKBOX Yes FORMCHECKBOX No Supporting documentation accompanying this application. Please check off: FORMCHECKBOX CME’s for immediate past 3 years (at least 90 hours required). FORMCHECKBOX Copy of American Board of Neurological Surgery Certificate in pdf format. FORMCHECKBOX Copy of Certificate from Fellowship Training in pdf format. FORMCHECKBOX Letter of good standing from current hospital, institution. FORMCHECKBOX Copy of Medical License in pdf format. FORMCHECKBOX Provide a case log that satisfies ABNS criteria – a chronological case log of 150 consecutive, major, surgical cases for which he or she was the responsible surgeon. Each must have a minimum of three months follow-up. All cases must be within an 18-month time period and none may be older than 24 months at the time received. A list of minor procedures must be included with the application as well. Case log must be in ABNS format. CASE LOG REQUIREMENTS FOR CERTIFICATION by the ABNS/ABPNS or ABPNS/RCPSC:Provide a case log that satisfies ABNS criteria: “Candidates for initial certification must submit a chronological log of 150 consecutive, major, surgical cases for which he or she was the responsible surgeon. Each must have a minimum of three months follow-up. All cases must be within an 18-month time period and none may be older than 24 months at the time received. A list of minor procedures must be included with the application as well.” In addition, case log evidence of a minimum of 95 major pediatric cases (with 3 month follow-up) within the 150 major consecutive cases submitted. Please note that the application must be completed and in the hands of the Credentialing Committee by April 1st for review at the June Board meeting or by October 1st for review at the December Board meeting. If your application is approved by the Board you will be eligible to sit for the examination. If your application is incomplete or received after the deadline date, your application will be processed for the following test date and the case log may need to be updated. Please submit this application and the supporting documentation listed above electronically via e-mail to john.ragheb@.By signing below, I hereby verify that all information submitted in this application for certification by the American Board of Pediatric Neurological Surgery is true, accurate and completed to the best of my knowledge and belief. I hereby request certification by the American Board of Pediatric Neurological Surgery. I understand that certification will require the submission of an operative case log and the successful completion of a written examination. Electronically signed by: _____________________________ (type in your name to verify above)Date: ______________ ................
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