FCCM Mentorship Program - Mentee Application

The FCCM Mentorship Program is a longitudinal program offered by the SCCM Texas Chapter that provides members with guidance and support in their professional development and preparation for application and a Fellow of Critical Care Medicine. This program focuses on development of strong characteristics aligning with the core areas of a competitive FCCM application.

Please complete all information below to submit your name as a mentee in this program.

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* 1. Name

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* 2. Email

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* 3. Phone

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* 4. Profession

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* 5. Practice population

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* 6. Years out of training

< 1 year

1 - 3 years

3 - 5 years

5 - 10 years

> 10 years

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* 7. Current city

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* 8. Current employment institution

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* 9. Preferred communication style

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* 10. Please check all that apply:

Active member of the Society of Critical Care Medicine at the Professional or Select level for two consecutive years immediately prior to application

Licensed (if license available) to practice in a healthcare category

Have a certificate of special competence in critical care or its equivalency based on your profession for the past two years

Devoted at least 50% of time to critical care in practice, research, administration, or teaching for at least two years

At least five years post-training involvement in the field of critical care

Current member of the SCCM Texas Chapter

The following areas are heavily reviewed by the FCCM Credentials Committee. Your current achievements in these areas will help your mentor determine initial feedback. Please utilize bullet points to summarize your contributions in these areas.

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* 11. PROGRAM DEVELOPMENT
Active participation in the development of or personal improvements to home institution preexisting programs or systems related to any aspect of critical care, including clinical, educational, research and administrative programs.

Examples of such activities include:
•         Implementation of the critical care intensivist model to an ICU
•         Development or organization of local, regional, or national critical care educational symposium
•         Development of regional/state/national programs related to clinical management of the critically ill
•         Development of critical care training programs, such as critical care fellowship programs
•         Development of ICU-related research programs
•         Development of novel local educational/clinical programs if emulated by other organizations
•         Development of quality improvement activities and evidence of improvement of patient care

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* 12. STATE/NATIONAL/INTERNATIONAL ENGAGEMENT
Activities in this area include participation and leadership in organizations devoted to education, practice, administration and/or research in collaborative multiprofessional critical care. Involvement in the SCCM is desirable but not required. Committee or task force work within the applicant’s hospital or organization, as part of their regular job, does NOT meet this requirement.

Examples include:
•         Committee service chairmanship
•         Elected or appointed positions
•         Verifiable active membership in task forces

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* 13. SCHOLARLY ACTIVITIES RELATED TO CRITICAL CARE
This includes educational activities, research (in areas related to critical care), and publications. Educational accomplishments may include activities in critical care education directed toward physicians, nurses, students, allied health professionals and/or the lay public.

Examples include:
•         Editorial Review Activities in high impact journals
•         Lectures on a regional/national/international level
•         Original scientific peer-reviewed publications
•         Multiple peer-reviewed or non-peer-reviewed educational publications
•         SCCM or other national critical care society awards
•         High quality education award demonstrating excellence in teaching
•         Grants from local/regional/state/national granting agencies
•         Development of web-based critical care educational programs
•         Development of critical care regional/state/national educational symposium

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* 14. Please upload your CV

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