~Leadership Application This is the form/workflow for someone applying to serve in leadership on a committee. "*" indicates required fields Step 1 of 3 - Personal Information 33% Welcome , to SMA's Online Leadership Application Form. Completing this application is the first step towards leading the next generation of medical professionals through the art and science of continuing medical education. Our Mission To improve the quality of patient care through multidisciplinary, inter-professional education. LEARNING. from scientific research. EDUCATION. from the perspective of experience. ADVOCATING for best practice through out their organization. CONNECTING the Family of Medicine. Quality patient care requires a team... a Family. Foundational Principles COLLABORATION. "The whole is greater than the sum of its parts." We believe in fostering relationships with organizations with similar and complementary missions and memberships. ACADEMIC ENGAGEMENT. Our mission centers on education, so it's imperative that we engage with and support the efforts of medical schools, residency programs, academic medical centers, and health systems by supporting the professional development of the next generation of healthcare providers. YOUTH ENGAGEMENT. We acknowledge the needs and concerns of medical students, residents, physicians, and health care providers of all types; the importance of supporting their professional development and passing along knowledge and experience from one generation to the next. Your application will be processed once you click submit. The review process takes 5-10 days. Thank you for your willingness to serve! Randy Glick, BSB/pm, MCP Executive Director rglick@sma.org 205-421-4189 Hiddenusername* HiddenCurrent Member Level Personal InformationFirst Name*Use proper case Last Name*Use proper case Degree(s)*Enter exactly how you want displayed. Email Mobile Phone*Enter the number you want leadership specific text messages sent to. This is strictly used for SMA Leadership business and will not be included in any marketing of any kind... including SMA marketing. This is exclusively used for keeping you updated on committee business.Your Profession* MD DO Nurse Physicians Assistant Resident Student Other Other Profession* Mailing Address*We likley already have this on file however please enter so we can confirm we have the most recent information. Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Availability (Days and Start Times)*Fitting "SMA business" into your already busy schedule is important to us therefore we try to schedule our time for conference call when its convenient for you. Please List the best start times for calls for each day below. These are just target times that will help us better determine when to setup calls. Round to whole or half hour. Leave blank for NAMondayTuesdayWednesdayThursdayFriday Add RemoveProfessional InformationProfessional Photo*This must be a JPG or PNG Drop files here or Select files Accepted file types: jpg, png, Max. file size: 29 MB, Max. files: 1. CV/Bio*This must be in PDF or MS Word Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 29 MB, Max. files: 2. Brief Public Bio Sketch*Brief bio that we can publish on our website and distribute through social media.Leadership and Educational InterestCommittee Position you are most interested in?* Education Committee Outreach Committee Physicians-in-Training Committee EDUCATION COMMITTEE. Shall oversee the development of all educational activities and programming for the Association to ensure the Association fulfills its stated CME mission. The Education Committee will serve the Association through content review, content recommendation, speaker recommendation and procurement, as well as offer direction with regard to grants and sponsorships. Composition: The Education Committee is composed of one (1) Physician Member (MD/DO) serving as Chair and any number of Active Members of any member classification as deemed necessary by the SMA Board of Directors. Qualifications: All Members must be active dues paying members in good standing. Selection: The Committee reviews and approves members who are eligible. The Chair is elected by its Committee Members. Creation of Sub-Committees and Sub-Committee appointments are at discretion of the Committee Chair. Term: Both the Chair and Members serve for a period of two (2) years and may be reappointed for additional terms. Removal: Removal of the Chair or any committee member requires a simple majority vote of the committee members or the SMA Board of Directors. Educational Interests*Choose the academic activities you would like to participate in. Abstract Reviewer Activity Planning Creating SMArt Bowl Questions Journal Reviewer Moderating Sessions Podcast Host Webinar Presenter SMA OUTREACH COMMITTEE Shall recommend the development of services to meet member needs, assist with communications to keep current members updated on relevant events and information, assist with promoting member awareness of the resources, services, and membership benefits, assist with the welcoming of new members, facilitating onboarding, and encouraging participation, and provide support in the development and communications of all fundraising activities including sponsorship, advertising, exhibiting, and endowments. Composition: The Committee is composed of one (1) Physician Member (MD/DO) serving as Chair and any number of Active Members of any member classification as deemed necessary by the SMA Board of Directors. Qualifications: All Members must be active dues paying members in good standing. Selection: The Committee reviews and approves members The Chair is elected by its Committee Members. Creation of Sub-Committees and Sub-Committee appointments are at discretion of the Committee Chair. Term: Both the Chair and Members serve for a period of two (2) years and may be reappointed for additional terms. Removal: Removal of the Chair or any Committee Member requires a simple majority vote of committee members or the SMA Board of Directors. Outreach Interests*Choose the academic activities you would like to participate in. Chapter Leader Fundraising Activitites Podcast Host Create Content on SMA Social Media Posting PHYSICIANS-IN-TRAINING COMMITTEE. Shall participate in the development and evaluation of educational activities and programming of the Association aimed at pre-medical students, medical students, interns, residents, and fellows. The Physicians-in-Training Committee will assist the Association in building the Association’s Foundational Pillar that recognizes that physicians in training have importance, special needs, and concerns, and will support their growth and development in their future healthcare careers. Composition: The Physicians-in-Training Committee is composed of one (1) medical student (MD or DO track) or house officer (intern, resident, or fellow; MD or DO) serving as Chair and any number of members, with a majority of the Committee members being medical students or house officers. Qualifications: The Chair and all members must be in good standing. Selection: The President-Elect reviews and approves members who are eligible The Chair is elected by its Committee Members. Creation of Sub-Committees and Sub-Committee appointments are at discretion of the Committee Chair. Term: Both the Chair and Members serve for a period of two (2) years and may be reappointed for additional terms. Removal: Removal of the Chair or any Committee member requires a simple majority vote of the committee members or the SMA Board of Directors. PIT Sub-Committee Position you are most interested in?* Outreach Personal Development and Wellness Mentoring and Networking Research and Development Physicians in Training Interests*Choose the academic activities you would like to participate in. Journal Reviewer Abstract Reviewer Creating SMArt Bowl Questions Moderating Sessions Podcast Host Webinar Presenter Chapter Leader Share why you desire to serve on this committee.* Financial Disclosure and Conflicts of Interest Disclosure and ResolutionThank you , for taking the time to complete this form so we are able to discover and resolve any conflicts of interest for this educational activity. As you answer these questions, the system will guide you through resolving any issues that may arise. SMA is accredited by the ACCME to provide continuing medical education for physicians. We appreciate your help in partnering with us to follow accreditation guidelines and help us create high-quality education that is independent of industry influence. In order to participate as a person who will be able to control the educational content, we ask that you <b>disclose all</b> financial relationships with <b>any ineligible companies</b> that you have had over the past <b>24 months.</b> We define ineligible companies as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; you must disclose all financial relationships, regardless of the amount, with ineligible companies. We ask you to disclose regardless of whether you view the financial relationships as relevant to the education. For more information on the Standards for Integrity and Independence in Accredited Continuing Education, please visit accme.org/standards. If you have any questions as you progress through this please contact us directly. Thank you Southern Medical Association education@sma.org Are you an employee of an ineligible company?*Ineligible companies are defined as those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. ACCME Ineligible Company Definitions: https://www.accme.org/faq/what-accmes-definition-ineligible-company Yes No Do you have any financial relationship(s) with ineligible companies occurring within the past 24 months?*Ineligible companies are those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. There is no minimum financial threshold; individuals must disclose all financial relationships, regardless of the amount, with ineligible companies. Yes No Disclosure of ALL Financial Relationships*Enter the Name of Ineligible Company An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. For specific examples of ineligible companies visit accme.org/standards. Enter the Nature of Financial Relationship Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual’s institution receives the research grant and manages the funds. Has the Relationship Ended? If the financial relationship existed during the last 24 months, but has now ended, please indicate this in this column. This will help our education staff determine if any mitigation steps need to be taken. ** Use "+" to add additional disclosures**Name of Ineligible CompanyNature of Financial RelationshipHas the Relationship Ended (Yes or No) Add RemoveAwareness of Actual and Potential Conflicts*In your disclosure you identified affiliation with ineligible company(s) that may or may not influence your participation in this activity. Owners or employees of companies shall not be permitted to participate as speakers or other contributing faculty, except in three ACCME-permitted exceptions. Please disclose by checking all that apply. When the content is not related to the business lines or products of the employer/company; When the content is limited to basic science research and they do not make recommendations; and/or When acting as technicians to teach the safe and proper use of medical devices and do not make recommendations. None of the above exceptions apply, therefore I will need further mitigation Do you have any financial relationship(s) you are unable to disclose?* Yes No Undisclosable Financial Relationship Description*Please describe relationship(s)Undisclosable Financial Relationship Documentation*Please upload documentation explaining why you are unable to disclose your financial relationships. All documents must be PDF format Drop files here or Select files Accepted file types: pdf, Max. file size: 29 MB, Max. files: 3. Other DisclosuresPlease describe here anything else you would like to disclose. Pledge I agree not to solicit or accept any gift, loan, gratuity, or service where such gift, loan, gratuity or service is of other than nominal value and where the person making such gift, loan or gratuity or performing such service is presently doing business with the Southern Medical Association, or has in the immediate past done business with the Southern Medical Association and may reasonably expect to do business in the immediate future with the Southern Medical Association. Any item or service having a value in excess of $1,000 shall not be deemed to be of nominal value. I, recognizing the responsibility I am undertaking in serving within a leadership role, and pledge to carry out my duties in a trustworthy and diligent manner. I acknowledge that my primary role is to actively contribute to the mission, individual projects, and business objectives of the organization. I agree to remain apolitical as it pertains to education and agree to work with and respect the opinions of my peers who serve. I agree to attend the majority of all meetings on which I am assigned. I agree to come prepared to all scheduled meetings, having reviewed all material relevant to the agenda. I agree to always act for the good of the organization and its members, rather than my own. I agree to represent this organization in a positive and supportive manner at all times. I agree to observe the parliamentary procedures and display courteous conduct in all meetings. I agree to refrain from intruding on administrative issues that are the responsibility of management except to monitor the results and prohibit methods that conflict policy. I agree to avoid conflicts of interest. If such a conflict does arise, I will declare that conflict before the Committee and refrain from voting on matters in which I have conflict. I agree to support in a positive manner all actions taken even when I am in a minority position. I agree to participate in strategic planning, self-evaluation programs, and development workshops, seminars, and other educational events that enhance my skills as an SMA Leader. If, for any reason, I find myself unable to carry out the above duties as best as I can, I agree to resign my position as a Board/Committee member/officer. Leadership Pledge Acknowledgment* I affirm all that I have stated above is accurate and true. SignatureHiddenInternal Eligibility ConfirmationConfirm Eligibility for the PositionMake sure this person is eligible to serve in the position they are requesting. Yes No HiddenEligibility or Disqualification NotesHiddenReviewer 1 - Executive Director*SelectAndrew SephienBenjamin LoftisBritton EthridgeBuckley McCallCaroline BrancheCary CavenderChristopher JacksonDaniel MorrisDavid BellDavid NetscherDenisse Camille DaytoDesiree Burroughs-RayDipakkumar PandyaDonald DiPetteDonna BreenElizabeth EdwardsG Waldon GarrissGlenn TalboyGloria CasaleJ David BaxterJennifer PriceJoanna ElhajJohn PierceKatherine Ruiz GonzalezKendra BlackmonKenneth GuiceKenneth Paikkondakuttan15486Lawrence CarterLeo MellerLoretta LoftusMackenzie PargeonMark WilliamsMary IlesoMichael BramanMohammed SingapuriNausherwan Burkiolanrewaju OnasanyaRaj PatelRandall GlickRandy GlickRanjodh GillRhonda WilliamsRichard GriffinRichard LeggettRitika KumarRodney OverstreetRonald CohnRyan AycockRylee WhiteSophia NavajasSteven BaldwinSteven StrodeStuart GoodmanSusan GonzalezSwetha VanjaThomas HestonThomas NucktonTina PhanTrent PercyHiddenReviewer 1 - Approval/Disapproval* Approve Disapprove HiddenReviewer 1 - Executive Directors Note to ChairHiddenReviewer 2 - SMA President*SelectAndrew SephienBenjamin LoftisBritton EthridgeBuckley McCallCaroline BrancheCary CavenderChristopher JacksonDaniel MorrisDavid BellDavid NetscherDenisse Camille DaytoDesiree Burroughs-RayDipakkumar PandyaDonald DiPetteDonna BreenElizabeth EdwardsG Waldon GarrissGlenn TalboyGloria CasaleJ David BaxterJennifer PriceJoanna ElhajJohn PierceKatherine Ruiz GonzalezKendra BlackmonKenneth GuiceKenneth Paikkondakuttan15486Lawrence CarterLeo MellerLoretta LoftusMackenzie PargeonMark WilliamsMary IlesoMichael BramanMohammed SingapuriNausherwan Burkiolanrewaju OnasanyaRaj PatelRandall GlickRandy GlickRanjodh GillRhonda WilliamsRichard GriffinRichard LeggettRitika KumarRodney OverstreetRonald CohnRyan AycockRylee WhiteSophia NavajasSteven BaldwinSteven StrodeStuart GoodmanSusan GonzalezSwetha VanjaThomas HestonThomas NucktonTina PhanTrent PercyHiddenReviewer 2 - Approval/Disapproval* Approve Disapprove HiddenReviewer 2 - SMA Presidents Note to ChairHiddenReviewer 3 - Committee ChairSelectAndrew SephienBenjamin LoftisBritton EthridgeBuckley McCallCaroline BrancheCary CavenderChristopher JacksonDaniel MorrisDavid BellDavid NetscherDenisse Camille DaytoDesiree Burroughs-RayDipakkumar PandyaDonald DiPetteDonna BreenElizabeth EdwardsG Waldon GarrissGlenn TalboyGloria CasaleJ David BaxterJennifer PriceJoanna ElhajJohn PierceKatherine Ruiz GonzalezKendra BlackmonKenneth GuiceKenneth Paikkondakuttan15486Lawrence CarterLeo MellerLoretta LoftusMackenzie PargeonMark WilliamsMary IlesoMichael BramanMohammed SingapuriNausherwan Burkiolanrewaju OnasanyaRaj PatelRandall GlickRandy GlickRanjodh GillRhonda WilliamsRichard GriffinRichard LeggettRitika KumarRodney OverstreetRonald CohnRyan AycockRylee WhiteSophia NavajasSteven BaldwinSteven StrodeStuart GoodmanSusan GonzalezSwetha VanjaThomas HestonThomas NucktonTina PhanTrent PercyHiddenReviewer 3 - Chair Approval/Disapprove* Approve Disapprove HiddenReviewer 3 - Committee Chair NoteHiddenReview Score*HiddenOnboardingHiddenCommittee Group Email* HiddenName of Committee Chair*Please use FULL NAME, proper case, punctuation, and degrees HiddenEnter Committee Chair Email* HiddenName of Staff Liaison*Please use proper case, punctuation, and degrees HiddenStaff Liaison Email* HiddenStaff Liaison Phone*Enter the phone number you want leaders to use to contact you.HiddenOffice Start Date*This date is the date this person was accepted in this system. MM slash DD slash YYYY HiddenOffice Begin Term Date*This is the date of the last day of the next annual meeting on the calendar. Each persons actual term will begin once the Annual Meeting has concluded each year. MM slash DD slash YYYY HiddenOffice End Term Date*This date is exactly one year from the Office Begin Term Date. MM slash DD slash YYYY HiddenNews Post URL*This is the standard news post we put on our site. This needs to be setup and posted live and the URL added here. HiddenConfirmed, Leadership Page is Updated and Accurate*This check box just demonstrates all the onboarding activities have been completed Confirmed
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